CRITICAL THINKING 6

RESEARCH STRATEGY

A. SIGNIFICANCE

A.1. COVID-19 created a profound disruption in healthcare: Covid-19 has upended U.S. health care. While most health systems rapidly activated emergency response plans and cancelled all non-urgent procedures and clinic visits, they experienced major negative financial impacts from the pandemic. The nonclinical workforce was often shifted to work-from-home and virtual communication with patients using telehealth exploded. As Slotkin et al. (2020) marveled, “the profound disruption in just 12 weeks of an industry, a century in the making, is astounding.” Health systems around the country have struggled to deal with critical aspects of care delivery, management, decision-making, workforce deployment, communications, and operations in response to the COVID-19 pandemic.

A.2. Lessons need to be learned, disseminated and implemented within a very short timeframe: It is imperative to analyze and evaluate the response of a variety of health systems to the pandemic and derive lessons learned, best practices, guidelines, tools, models, processes, and systems that can and should be disseminated and implemented now and in the future. Specifically, we will study the organizational response of the fourteen hospitals comprising the HCA Healthcare East Florida Division and will study the response at all levels – provider, unit, hospital, division and corporate – along with interactions among and between organizational levels. In accordance with this RFA (RFA-HS-20-003), we have organized our project as “rapid- cycle research” (AcademyHealth, 2020). That is, the proposed project is driven by the questions health system leaders have today; will be conducted in nine months; balances responsiveness with the most rigorous methods possible; and supports learning within a health system as well as broad dissemination of results and learnings to other health systems. It focuses on how decisions and innovations made during the response can best inform operations in the future, during times of normal operations and during public health emergencies.

A.3. There are large variations in health systems response effectiveness: While some health systems, such as HCA Healthcare, Kaiser Permanente, and Geisinger, have been very successful (Slotkin et al., 2020), others have not fared as well (Ramachandran et al., 2020) in their response to the pandemic. It is clear that a number of areas have been problematic for many health systems around the country including, but not limited to: inadequate preparedness, preparation and planning, improper patient transfers, insufficient isolation protocols, inadequate staff planning and training, ineffective communication systems and messaging, insufficient coordination and collaboration within and across systems, procurement planning gaps, incomplete staff protection policies and procedures, overreliance on government sources of equipment and assistance. Thus, a portfolio of health systems, with various degrees of success and differing characteristics need to be studied. We propose to focus on, and learn from, HCA Healthcare, the largest hospital and health system in the United States (Becker Hospital Review, 2019), with a focus on its East Florida division (see rationale below).

A.4. Despite existing guidelines, healthcare preparedness and response capabilities remain very limited: As depicted in Figure 1 (Joint Commission on Accreditation of Healthcare Organizations, 2002), an emergency management plan must address four phases of disaster management: mitigation, preparation, response, and recovery. The model portrays response as the biggest and most visible. It places mitigation and preparation at the base, portraying them both as the driving forces behind a successful response. Recovery is at the top because it is what remains after the response. Various government organizations have established guidelines, standards, or tools designed to help health care organizations manage operations during and after a disastrous event including the Centers for Medicare and Medicaid Services, the National Academy of Medicine, and the Office of the Assistant Secretary for Preparedness and Response. Despite these efforts, healthcare preparedness remains inadequate (Niska and Shimizu, 2011; Goodwin et al., 2016; Ramachandran et al., 2020). In a cross- sectional study of 45 hospitals in Los Angeles County, Kaji and Lewis (2006) found that disaster preparedness and surge capacity were limited by a failure to fully integrate interagency training and planning and a severely limited surge capacity. In a systematic review, Potter et al. (2010) studied the effectiveness of preparedness training materials and found that while topics cover leadership and command structure (18.4%), information and communications (14.1%), organizational systems (78.5%), and others (23.9%), their usefulness for trainers and educators was rated as low.

A.5. While strategies, plans, and guidelines are necessary, they are not sufficient: Keating-Duley (2005) emphasizes four major objectives each state must undertake to assure health care facility preparedness: (1)

Figure 1: Emergency Management

Develop strategies to maximize staffed beds; (2) Develop strategies to cope with the potential staffing shortages; (3) Develop strategies to deal with potential critical equipment shortages; and (4) Implement education, training, and communication strategies for health care workers and the public. While these “capacities” are necessary, health organizations need to build a culture of responsiveness, adaptability, learning, and agility and need to develop, implement and integrate congruent “capabilities” - actions, tools, models, processes, and systems - within the fabric of the organization. For this study, we developed a novel organizational change framework to comprehensively analyze which organizational factors turn capacities into capabilities that quickly enable performance and desirable outcomes in response to an exogenous unexpected external threat. Just as a culture of safety has been shown to be necessary to improve safety (Morello et al., 2013), a culture of responsiveness, adaptability and agility is deemed necessary in this research, and will be investigated.

A.6. We forged a unique affiliation with HCA Healthcare, the largest hospital system in the U.S. (Becker Hospital Review, 2019): With Nova Southeastern University’s (NSU) aggregate investments of over $1.5 billion

in health care, including the most recently accredited Medical School in the U.S., The NSU-HCA relationship is governed by legally-binding affiliation agreements that span the entire continuum of education and research, ensuring that the data sources are secure for project access and reliably available for project purposes. NSU is the largest private institution in the U.S. that meets the U.S. Department of Education’s criteria as a Hispanic- serving Institution. NSU is the largest independent, not-for profit, university in Florida and the Southeastern U.S. NSU will analyze the response of the 14 hospitals comprising the HCA East Florida Division (HCA EFD) as well as collaborate with HCA Healthcare Corporate and the HCA Research Institute (see enclosed letter of commitment/emails speaking to collaboration with HCA personnel). HCA EFD is the largest and most resourced Division of HCA and serves a large, diverse population within the South Florida market.

A.7. The proposed project focuses on a diverse population: The State of Florida has been experiencing dramatic population growth, especially the major tri-county, East coast markets of Palm Beach, Broward, and Miami-Dade Counties. Prior to COVID-19, Florida’s significant population growth reflected a growing business community, low unemployment rates, a broad scope of opportunities, and an influx of immigration from other states and nations. From 2010 to 2017, Florida’s population grew by 11.6%, versus only 2.4% in New York. One of the aspects of Florida that make it so unique is its diversity. Its residents include people from a wide variety of ethnic, racial, national, and religious backgrounds. The state attracts immigrants from other nations, particularly from Latin America. Florida has one of the largest African American populations in the country (including Afro- Caribbean) and has the second highest Latino population on the East Coast outside of New York state. The ethnic Asian population has grown rapidly, the majority are Filipinos, Vietnamese, and ethnic Chinese. The state has several federally recognized American Indian tribes, such as the Seminoles and Miccosukee. These data underscore the immense opportunity we have in South Florida to study health system response to the COVID- 19 pandemic in the context of unique populations of people, many of whom are underserved, understudied and vulnerable. A key aspect of an effective COVID-19 response on behalf of health systems in the State of Florida is cultural competence. Effective and efficient population management in this state requires that the response support cultural differences uniquely present in the diverse South Florida population.

A.8. Over twenty percent (20.5%) of the State of Florida population is age 65 years or older: Another dimension of population vulnerability in the State of Florida is its aging population. With 20.5% Floridians ages 65 and over, the state ranks second in the U.S. only to the State of Maine, which is nearly identical at 20.6% (Himes & Kilduff, 2019). Migration, both internal and international, has had a large impact on the distribution of older adults in Florida as has Florida’s attraction to older retirees. In the COVID-19 pandemic, older adults are at a significantly higher risk for critical illness and mortality, with 93.6% of all COVID-19 deaths in the State of Florida as of June 3, 2020 attributable to people age 55 years or older (CDC, 2020).

A.9. The response to the pandemic in Florida has been effective: As shown in Figure 2, according to Covid Act Now (2020), the current COVID risk level in Florida is medium. Despite dramatic predictions to the contrary, COVID in Florida is spreading in a slow and controlled fashion. In Florida, the infection rate is 1.07%. The positive test rate is 4.6%, and the ICU headroom used is 10%. On average, each person in Florida with COVID is infecting 1.07 other people, which means that COVID is still spreading in Florida, but in a slow and controlled fashion. COVID spread in Florida as of June 11, 2020 is shown in Figure 3. Figure 2: COVID Risk Level in FL

Florida has about 6,059 ICU beds. The State of Florida estimates that 48% are currently occupied by non-COVID patients. Of the remaining 3,151 ICU beds, Florida estimates 327 are occupied by COVID cases, or 10.4% of available beds, as of June 11, 2020 (Covid Act Now, 2020).

A.10. The proposed study will have a large impact: HCA East Florida Division has 14 hospitals, 12 surgery centers and 21 ER locations serving eight counties in Florida that in total account for over a third of the total population in the State. In 2019, The total number of patients treated by HCA East Florida amount to just under 20% of the total population in the eight counties. They also account for 27% of the Medicaid patients and have treated approximately 200,000 uninsured patients. Given the socio-demographic characteristics of the State of Florida population, this project will have a significant direct impact on a large, diverse, and vulnerable population, just through the HCA East Florida Division. In addition, dissemination of results to the national HCA Healthcare system and to other healthcare systems in the U.S. will result in an even larger impact.

B. INNOVATION

This RFA presents an unprecedented opportunity for systematically investigating issues such as workforce deployment, space reallocation, communications between settings, and how decisions affected patient and workforce experience and outcomes in the face of the COVID-19 pandemic. The proposed study is innovative in a number of important ways and has a number of unique distinguishing features (Table 1).

B.1. The study is designed to understand how decisions and innovations made during the response can best inform operations today and in the future, both during normal times and in public health emergencies.

B.2. We have partnered with HCA Healthcare, the largest hospital and health system in the United States (Becker Hospital Review, 2019).

B.3. The evaluation will incorporate considerations of both patient health and safety as well as employee health and safety as the study builds on the healthy organization model (Sainfort et al., 2001).

B.4. This project makes a novel contribution to organizational change theory: The framework proposed in this study adds a new perspective to the current state-of-the-science reflected in the organizational change literature. It will further our understanding of healthcare system preparation and response to significant external threats and disruptions of the magnitude of the COVID-19 pandemic.

B.5. This project will generate new knowledge, practices, tools, processes, models, systems to advance healthcare preparedness, response and outcomes in the face of pandemic and other crisis situations. Beyond the generation of practices and guidelines, though an innovative dissemination and implementation plan, this project will produce a suite of assessment and management tools (e.g., prediction, simulation, staffing allocation, resource allocation, process maps) as well as strategies regarding the role of organizational factors such as the importance of adopting and building a culture of organizational and individual responsiveness and agility. Many of the research products will be immediately available, while others will require additional research and development.

Figure 3: COVID Infection Rate in FL

Table 1: Distinguishing Features of this Proposal

C. APPROACH

C.1. Conceptual Framework

The literature on organizational change and organizational behavior is extremely large, precluding a comprehensive review. The purpose here is to select key models from the literature that address different types of change applicable to health system responsiveness to a major disruptor. Of particular interest are: 1) the organizational factors that drive change within organizations; 2) the factors that influence organizational response to changing environments, especially sudden, unexpected, threats; and 3) the factors that influence the impact of organizational response on outcomes. The goal, then, is to build a theory-based conceptual framework to guide the design and execution of the proposed research.

The conceptual framework derived for this research is shown in Figure 4. It incorporates selected theories of organizational change drawing primarily from the resource-based view of the firm (Miles and Snow, 1978; Barney, 1991), the organizational fitness model (Voelpel SC, et al., 2004), organizational learning and agility (Argyris and Schon, 1995; Jacko et al., 2002; Dyer and Ericksen, 2007), and the healthy organization model (Sainfort et al., 2001). Figure 4 depicts factors that are critical in considering the organizational response (B) to an exogenous shock (A) such as COVID-19 that leads to certain outcomes (C).

This research is being conducted by first conceptually developing and then empirically testing a set of hypotheses that predict interrelatedness between internal resource profiles and organizational responses. It blends two major areas of the strategic management ideology: 1) the influence of the external environment (D in Figure 4) on organizations; and 2) the influence of resources (E in Figure 4) on organizational response to exogenous shock and the external environment.

The resource-based view posits that an organization’s internal resources are a means of organizing processes and obtaining a competitive advantage (Barney, 1991). The resource-based view suggests that organizations must develop unique, firm-specific core competencies and capacities (F in Figure 4) that will enable them to do things differently, adapt to unexpected conditions, and achieve strategic goals that maximize desired outcomes. These capacities include work systems and processes put in place, the structure of the organization, its technologies and equipment, key capacities such as supply chains, logistics, and, most importantly, its human capital, the workforce, the leadership and the culture of the organization (Lawrence, Tworoger, Ruppel, 2014).

Heracleous and Barrett (2001) suggest that deep structures, persistent and stable processes and patterns that influence action, in organizations, shape the change process. Managers, or change agents, with extended knowledge of these deep structures are necessary in the enactment of change. Miles and Snow (1978) propose that an organization's strategic type will influence decisions regarding strategy, structure, and process. They developed a framework for classifying organizations as Defender, Prospector, Analyzer, and Reactor. This framework has been utilized to study response in the hospital industry (Meyer, Brooks, and Goes, 1982). These studies suggest that the strategic “type” of an organization will influence its reaction to regulatory change, technological change, and jolts from the environment. A common theme is that an organization's strategic “type” influences how it receives and perceives information about changes in its environment and therefore, how it

Figure 4: Conceptual Framework

responds to that information. Thus, the resource-based view suggests that resources greatly influence outcomes and organizational success.

However, our conceptual framework also posits that, while resources are critical, organizations are greater than their bundle of resources. Internal practices, knowledge, and managerial decisions about obtaining and utilizing resources may be stronger strategic factors influencing response to shifts in external environments.

The organizational fitness model refers to these as “capabilities” (G in Figure 4). Organizational fitness (Beer and Eisenstat, 2000; Beer and Nohria, 2000; McCarthy and Tan, 2000; Beer, 2003) is defined as an organization’s ability to adapt and survive in the ever-changing business environment, and is achieved through proactive reaction in the face of disruption, natural evolution, and purposeful change. Capabilities are defined as the actual ability of the organization to fully activate its capacities to achieve certain levels of organizational performance (H in Figure 4). Organizational capabilities include coordination, decision making, planning, communication, competence, commitment, creativity, capacity management and use, all of which correspond to redesigned and restructured organizational capacities, which in turn directly influence organizational performance. In studying healthcare systems, which are organizations that 1) require a very high level of knowledge, skills, and technology and 2) deal with very high levels of uncertainty and ambiguity in delivering healthcare services, these capabilities are paramount as is the ability of the organization to incessantly learn and transform. Hence, the feedback loop leading to organizational learning and agility (depicted as I in Figure 4). As pointed out by Prahalad and Hamel (1990) focusing on core organizational competencies creates unique, integrated systems that reinforce fit among the organization’s diverse production and technology skills—a systemic advantage with the ability to immediately respond to change.

The conceptual framework proposed for this study is aligned with the concept of healthy organization (Sainfort et al., 2001), which integrates Donabedian’s well-known structure-process-outcome quality measurement model (1981) with Murphy and Cooper’s human factors model of a “healthy work organization” (2000). It posits that balance between environmental, technological, organizational, and cultural factors is necessary to achieve optimal desired outcomes at the individual, team, and organizational levels. Congruent with stakeholder theory (Freeman, 1984; Phillips, 1997; Arganadona (1998), it also stresses the importance of ethics (Sims and Kramer, 2015) which is highly relevant in healthcare and a critical aspect of culture. More importantly for this particular project, it also emphasizes that both patients’ quality and safety outcomes AND healthcare workers’ work life quality and safety outcomes are intertwined goals and objectives of the organization and are critical to organizational effectiveness and sustained performance. Thus, we posit that outcomes of hospital organizational response to COVID-19 need to include both measures of patients AND healthcare workers outcomes.

C.2. Investigative Team and Expertise

As shown in Table 2, our research team is uniquely qualified to successfully perform this research. Three key personnel (Sainfort, Jacko and Vieweg) have each had continuous funding as PI or co-PI from Federal agencies (NIH, AHRQ, NSF, DOD) for over 25 years and bring tremendous research leadership experience to this project. They also routinely successfully collaborate together on research projects and scientific publications. They all recently joined NSU upon the creation of one of the newest medical schools in the nation and bring complementary expertise to this project. They are joined by talented faculty from the College of Business at NSU with extensive corporate experience in critical domains relevant to this project (Lawrence and Kramer). In addition, key senior personnel

Table 2: Research Team Expertise

at HCA Healthcare Corporate (Fromell) and HCA East Florida Division (Cornehls, Sakano and Whittaker) will lead and coordinate efforts within the HCA system. Finally, a consultant (Mervak) who served as former CFO for HCA Healthcare and currently serves as an adjunct professor at NSU, will assist and advise the research team.

C.3. Preliminary Studies

The PI (Sainfort) and other members of the investigative team (Jacko and Lawrence) have successfully led a number of organizational change studies in healthcare, including:

C.3.1. Radical Change in Primary Care Clinics: Sainfort and Moen (2011) implemented and studied an ambitious and comprehensive clinician-driven process of primary care practice redesign in all primary care clinics at Fairview Health Services in Minnesota. Fairview is one of the largest not-for-profit health care systems in Minnesota, with more than 19,000 employees working in seven hospitals, 38 primary care clinics and 34 specialty clinics throughout the state of Minnesota. Many of the methods proposed in this study were successfully employed in the Fairview project.

C.3.2. Implementation of Quality Improvement Methods into Local Public Health Departments: Riley and Sainfort (2009) studied how QI methods lead to organizational change in health departments in Minnesota.

C.3.3. Comprehensive IT Solution for Quality and Patient Safety: Under AHRQ grant UC1 HS015236, Sainfort (PI), Jacko (I), and their post-doctoral student (Edwards) studied and evaluated the implementation and impact of a suite of new Health Information Technologies on patient safety and quality in a large children’s hospital system in Atlanta. The research included organizational analysis and process mapping of two hospitals (Edwards et al., 2008a, Edwards et al., 2008b, Edwards et al., 2008c; Culler et al., 2009).

C.3.4. Facilitators and Barriers to Organizational Change: Under AHRQ grant R01-HS10246, Gustafson and Sainfort (co-PIs), examined facilitators and barriers to the implementation and adoption of computer-based health support systems in healthcare organizations. As part of the study, they developed and tested a novel decision theoretic model and practical tool to assess and predict the success of organizational change efforts (Gustafson, Sainfort et al. 2003). This is an 18-factor Bayesian model that estimates the probability of successful change and was empirically tested in a comprehensive study of 198 healthcare organizations undergoing organizational changes.

C.3.5. Quality Improvement in Nursing Homes: Under AHRQ grant R01-HS009746, Sainfort (PI) investigated the relationships between quality improvement strategies, organizational characteristics, job factors, and quality of care in 102 nursing homes in Wisconsin. As part of the study, Sainfort and his team conducted interviews, focus groups, observations and surveys (N=12,000) to assess nursing home employee quality of working life and its relationship to a) quality of care (using the resident assessment instrument [RAI] data); b) quality improvement transformational changes; and c) other organizational and structural changes (Sainfort et al., 2005).

C.3.6. Roadmap for Transformational Change in a Hospital Setting: Lawrence (co-Investigator) and her colleagues conducted a longitudinal study of how effective leadership and teamwork strategies can be employed during radical organizational change in a HCA hospital with the goal of developing models for organizational culture change that support better patient care (Lawrence et al., 2014, best paper at Decision Sciences Institute Conference, 2014).

C.4. Health System Partner and Patient Population

C.4.1. Health System Partner: Our hospital partner on this project is HCA Healthcare East Florida Division, which serves the South Florida region as its largest healthcare system, with 18,995 employees. Composed of 14 hospitals spanning eight counites including Miami-Dade, Broward, Palm Beach Counties, and the Treasure Coast, HCA East Florida includes 21 emergency departments and 12 ambulatory surgery centers, five Care Now urgent care centers, three trauma centers, one burn center, one regional laboratory, nine psychiatric programs, 31 teaching programs and 90 physician practice locations. HCA Healthcare is a collaborative healthcare network that extends a knowledge pipeline into every one of its facilities, creating one of the country’s most connected medical environments. HCA produces medical data from approximately 35

Figure 5: HCA EFD Catchment Area

million patient encounters a year. The catchment area for HCA East Florida is Shown in Figure 5. It covers eight counties in the State of Florida. HCA Healthcare is NSU’s preferred clinical partner. HCA Healthcare is constructing a new hospital on the campus of NSU in Davie, Florida. The hospital represents HCA’s single largest investment at $317 million. HCA East Florida already operates a free-standing emergency room facility on the NSU campus.

HCA Healthcare nationally fosters a large, diverse, and inclusive workforce of approximately 280,000 employees, of whom 72% are female, and 47,000 active affiliated physicians (HCA Healthcare, 2020). In addition to gender diversity, as shown in Figure 6, the HCA workforce is very diverse from a race and ethnicity perspective as well as from an age perspective. Thus, the workforce demographics will ensure excellent representation of both women and minority populations among the key informants who will be interviewed during this project.

Nationally, with 184 hospitals, more than 1300 physician practices, 104 freestanding emergency rooms, 230 telehealth facilities and 170

urgent care clinics, in 2019, HCA Healthcare accounted for about 35 million patient encounters and 9.2 million emergency visits (HCA Healthcare, 2020).

As a learning health system, HCA Healthcare collects and analyzes data from our approximately 35 million annual patient encounters to develop technologies and best practices that improve patient care in their facilities.

Three of the investigators on this proposal (Sainfort, Jacko and Vieweg) have been granted data access privileges and will work closely with Yuri Sakano, Division Director, of Nursing Analytics to mine relevant data systems to assist with the project.

C.4.2.: Patient Population: According to the Florida Department of Health (2020), the eight counties covered by HCA East Florida include the three most populous counties in Florida – the tri-county areas of Miami-Dade, Broward and Palm Beach counties - and in total represent more than a third of the total population of the State of Florida with a total population in 2018 of 6.8 million individuals. The tri-county area alone accounts for 88.9% of the 6.8 million people. In 2019, HCA East Florida treated over 1.3 million patients, including 280,000 Medicaid patients and 178,000 uninsured patients. HCA East Florida has a 27% Medicaid market share and serves a highly diverse and vulnerable population (HCA Healthcare East Florida Division, 2019). Indeed, in terms of race

Figure 6: HCA Workforce 2019

Table 3: HCA Catchment Area Race and Ethnicity Table 4: Other Social Determinants

and ethnicity, as shown in Table 3, across the eight counties covered by HCA East Florida, 42% of the population is Hispanic, 19% is non-Hispanic Black, 35% is non-Hispanic White and 4% is other. Table 3 also shows an uneven distribution of race and ethnicity across the eight counites with Miami-Dade having the largest percentage of Hispanics (68.6%) while Broward has the largest percentage of non-Hispanic Blacks (28.2%).

Table 4 further demonstrates that the population in the eight counties covered by HCA East Florida has specific vulnerabilities. The percentage of adults over the age of 65 years is 19% overall and varies from a low 15.6% in Miami-Dade County to a high of 34.8% in Highlands County. The percentage of individuals below the 185% poverty level is 34% overall and varies from 29.1% in Palm Beach County to 49% in Okeechobee County. The percentage of individuals without health insurance is 16% overall and varies from 11.5% in Martin County to 18.1% in Miami-Dade County. Finally, the rate of hospitalization per 100,000 is 12,373 overall and varies from 11,628 in Miami-Dade County to a high of 18,862 in Okeechobee County.

C.5. Methods

The project has the following three specific aims:

Aim 1. Conduct an in-depth retrospective and prospective organizational analysis to fully characterize the

response to the COVID-19 crisis developed and implemented by HCA EFD along with HCA Corporate

in terms of “practices”, including all facilitators, barriers, innovations, activities, plans, interventions,

processes, systems, models, and tools comprising, or affecting, the response.

Aim 2. Evaluate and characterize outcomes – perceived and actual – resulting from the organizational response

on a) the population of patients, with a particular focus on the elderly, b) the healthcare workforce, and

c) the organizational effectiveness, in order to determine, bundle, and prioritize best practices that can

be implemented in the new normal and/or the future, to optimize response to exogenous shocks.

Aim 3. Develop, initiate and implement an innovative multi-faceted dissemination and implementation (D&I)

plan that will optimize scalable and sustainable integration into existing practices. The D&I plan will not

only be comprised of the results of this proposed project but will also constitute a continuous systematic

review and integration of research performed by other grantees and the research community at large.

C.5.1. Aim 1 – Organizational analysis to characterize HCA EFD response to the COVID-19 crisis: HCA Healthcare is a large organization with a well-defined chain of command and matrix organizational structure. Therefore, the organizational analysis will be conducted at all levels – healthcare worker, unit, hospital, division and corporate, as shown in Figure 7. To achieve Aim 1, mixed methods to understand organizational response will be implemented including retrospective qualitative and quantitative methods: semi-structured interviews, focus groups, documents analysis, process analysis and mapping. The data collection efforts are designed to understand the breadth and depth of challenges and enablers to respond to the COVID-19 pandemic. Our strategy will be exploratory and sequentially refined (Devers, 1999), that is, early findings from contextual inquiry, initial interviews, followed by short follow-up questions will inform revision of interview guides and themes for focus groups. As explained in section B. Innovation, we have used mixed methodologies successfully in previous studies. Researchers with organizational change, process engineering, and clinical backgrounds will team up in qualitative data collection.

C.5.1.i. Methods – Environmental Scans. Throughout the duration of the project, we continue to perform environmental scans of the literature, beyond our current knowledge of the fields, to further guide design of interview/focus group questions. We will cover peer reviewed and other “gray” literature (e.g., governmental, professional society) related to hospital preparedness, organizational response, and crisis management.

C.5.1.ii. Methods – In‐depth interviews: We will conduct interviews with key informants among the leadership at the hospital, division and corporate levels. We will include approaches developed in Naturalistic Decision Making (NDM) to understand expertise in complex, real‐world decision making (Klein, 2008). One method developed in NDM research is cognitive task analysis, which uses “tough cases” in interviews to capture how people succeed in spite of significant challenges, and to focus on critical cues, strategies, exceptions, and practical solutions (Crandall et al., 2006; Militello and Hutton, 1998). NDM provides methods to capture the attributes of expertise that are difficult to articulate and often invisible (i.e., mental models, goals, effective motivators) but key to resilience and agility. As shown in Table 5, there are a large number of potential key informants. We plan to recruit all key informants at the corporate and division level and approximately 3 to 5 key informants at each of

Figure 7: Multilevel Analysis

the 14 hospitals. We collected all organizational charts and these individuals will be nominated by the HCA EFD leadership team on this project in conjunction with the CEO and/or COO of each hospital and the research team.

C.5.1.iii. Methods – Focus groups: We will recruit approximately 48 healthcare workers (physicians, nurses, and respiratory therapists – see Table 5) and conduct 4 focus groups at the healthcare worker level. In addition, we will recruit 2 to 3 individuals at the Unit and Hospital levels (see Table 5) from each of the 14 hospitals to conduct 3 additional focus groups. Focus groups will be used to incorporate group activities such as nominal group techniques (Van de Ven and Delbecq, 1972) to prioritize and quality functional deployment (Chaplin et al., 1999) techniques to drill down key factors of productive interactions between levels of organizations. Whenever possible, we will form mixed groups of professionals as opposed to homogeneous professional groups. Research team members with different backgrounds, led by qualitative researchers, will facilitate focus groups.

C.5.1.iv. Methods – Contextual Inquiry: We will, COVID-19 regulations permitting, organize site visits at the hospitals and division level to collect additional information and perform direct observations. Contextual inquiry involves researchers asking questions to the participants while conducting observations for clarification and soliciting more information based on what is observed. Direct observations, sometimes as part of contextual inquiry, are an essential organizational analysis method to look at contextual and other performance shaping factors and to understand how work is actually carried out (Catchpole et al., 2017).

C.5.1.v. Methods – Process Flow Analysis and Process Mapping: Following Shelton et al (2013), we will employ process analysis and process mapping to fully understand the response from the 14 hospitals, division and corporate headquarters to the COVID-19 crisis in East Florida. Process maps (see Figure 8) can reveal the sequence of steps required to generate a specific product or outcome. In this context, we will use them to show the series of activities required to successfully develop and implement elements of the organizational response. Of particular importance is to identify activities that are (1) critical to the success of the system or process, (2) most vulnerable to failure, (3) relevant across a wide range of threat scenarios, (4) readily observable, and (5) under the control or influence of the entity being analyzed.

C.5.1.vi. Methods – Document Analysis: We will collect and analyze all minutes, reports, plans, , tools related to the HCA organizational response to COVID-19 made available to the team by Corporate and the Division.

C.5.1.vii. Methods – Elements/Factors to Be Studied: Questions for semi-structured interviews and focus groups, as well as factors to be uncovered with other methods will be guided by the elements described in the conceptual framework (Figure 4). To ensure completeness, existing lists of questions and topics to be investigated will also be derived from recent reports (AcademyHealth 2020, National Academies, 2020) as well as the list of core elements by Cosgrove et al. (2007) in a report to AHRQ. Communication and teamwork play an important role in the response to COVID-19 at HCA EFD. We will use the TeamSTEPPS™ toolkit (AHRQ, 2019). to guide the inquiry. Sainfort successfully used it to document and team performance in a previous project (Riley et al., 2009).

C.5.1.viii. Methods – Analysis: We will begin analyzing the data during the collection of data and continue throughout the first six months and beyond. All the interviews will be audio/video recorded and transcribed to

Table 5: Aim 1 Key Informants and Methods

Figure 8: Key Elements in Process Mapping

ensure accurate data collection. All qualitative data, including field observations and the transcriptions from the focus groups and interviews, will be entered into Alas.ti, a qualitative data analysis software program, to support the analysis and organization of qualitative data. The mixed methods analysis will merge the qualitative findings by matching qualitatively elicited themes from the observations and interviews. Specifically, we will analyze using a consensual qualitative research approach with codes derived inductively. Any disagreements in coding will be discussed until consensus is reached. Using the constant comparative method, we will formulate the results in terms of a comprehensive list of “organizational practices” – facilitators, barriers, innovations, activities, plans, interventions, processes, systems, models, and tools – and full descriptions of each that, together, comprise or affect, the response. When appropriate, practices will be bundled into subset of distinguishable plans/activities.

C.5.1.ix. Social Distancing Constraints: By the time of notice of award, we anticipate that all aspects of these studies will be feasible assuming COVID-19 guidelines will allow researchers to be physically on-site, observing and interacting with key informants. As a contingency plan, all studies in all three Aims, at the exception of contextual inquiry which requires direct observation, will be successfully (and efficiently) implemented using video conferencing tools such as WebEx (used by HCA) and/or Zoom (used by NSU). We found that the proper use of these technologies have resulted in efficient interviews and effective group discussions in our preliminary interactions with our health system partner. These technologies also provide convenient and transparent recording capabilities.

C.5.2. Aim 2 – Evaluate and characterize outcomes – perceived and actual: The goal of Aim 2 is to evaluate and characterize outcomes – perceived and actual – resulting from the organizational response(s) on a) the population of patients, with a particular focus on the elderly, b) the healthcare workforce, and c) the organizational effectiveness, in order to determine, bundle, and prioritize best practices that can be implemented in the new normal and/or the future, to optimize response to exogenous shocks.

C.5.2.i. Methods – Patient Clinical Data: Data systems from HCA EFD will be queried to perform a pre-post analysis of clinical patient data to characterize potential changes from pre-COVID-19 to current date. HCA has a comprehensive electronic medical record system complemented by in-house data that provides a complete picture of quality of care, morbidity, mortality, safety, recovery for all COVID-19 patients that can be benchmarked against all other hospitals in the HCA system as well as against national benchmarks. Sub-analyses will include analyzing patient data by age and race/ethnicity. Data will be analyzed over time as well as across hospitals and contrasted to the relative number of COVID-19 patients seen in the different hospitals. We expect that a majority of affected patients will be elderly patients, as has been the case in the State of Florida in general, especially regarding mortality rates.

C.5.2.ii. Methods – Complementary Anecdotal Patient Clinical Data: In addition, HCA EFD has kept a comprehensive log of anecdotal data that can be analyzed to complement clinical data. Qualitative analysis will be performed to further document the impact of the organizational response on patients.

C.5.2.iii. Methods – Patient Satisfaction and Employee Satisfaction Data: Similarly, Data systems from HCA EFD will be queried to perform a pre-post analysis of patient satisfaction data and employee satisfaction data to further characterize potential changes pre-COVID-19 to current date. Hospitals in the system, with varying levels of COVID-19 patients, will be compared and contrasted.

C.5.2.iv. Methods – Operations Daily Logs: HCA EFD kept daily logs of all operational functions including supply chain management, utilization, logistics, vertical and horizontal communications, bed management and utilization. All data will be analyzed to characterize the success of the response from an operational perspective.

C.5.2.v. Methods – Human Resources Management: HCA EFD kept daily logs of training of all critical healthcare workers including nurses, respiratory therapists and other clinicians, transfers of healthcare workers across the system, recruitment, deployment and assignment changes, and handoffs. The data will be analyzed and evaluated to produce aggregate measures of the effectiveness of these operations.

Table 6: Sample Barriers

C.5.2.vi. Methods – Evaluation of Organizational Practices identified in Aim 1: We will use the nominal group technique (NGT, Van de Ven and Delbecq, 1972) with three groups of key informants (see Table 5) to rate the effectiveness of all organizational practices identified in Aim 1. We will use two groups of healthcare workers (2 or 3 individuals selected from each of the 14 hospitals) and one group of leaders at the unit and division level. In addition, a third group of healthcare workers will be used to assess potential barriers and obstacles perceived and how well they were mitigated. We will build on Timen et al. (2010) who identified 30 barriers among healthcare workers who had been actively involved in previous crisis situations due to infectious outbreaks. Table 6 shows a sample of the barriers uncovered. We will formulate a similar list for this particular step and employ the NGT technique to obtain consensus ratings.

C.5.2.vii. Analysis of Data: Table 7 depicts a sample of the outcomes and effectiveness measures as well as the sources. All data will be further analyzed and summarized so as to fully depict the extent of the multidimensional success of the organizational response. It will be further disaggregated with the goal of assessing the relative effectiveness of each of the organizational practices uncovered in Aim 1.

C.5.3. Aim 3 –Implement an innovative multi-faceted dissemination and implementation (D&I) plan: The goal of Aim 3 is to develop, initiate and implement an innovative multi- faceted dissemination and implementation (D&I) plan that will optimize scalable and sustainable integration into existing practices. The D&I plan will not only be comprised of the results of this proposed project but will also constitute a continuous systematic review and integration of research performed by other grantees and the research community at large. There is a significant body of literature on best dissemination and implementation strategies (Yuan, 2010; AHRQ, 2012; AHRQ, 2017; Ordoñez and Oliver, 2017; PCORI, 2012). At the simplest level, dissemination is best described as the delivery and receipt of a message, the engagement of an individual in a process, or the transfer of a process or product (Ordoñez and Oliver, 2017). Dissemination should serve three broadly different purposes: awareness, understanding, and action. Indeed, effective dissemination of a knowledge product will most likely require that it satisfies all three in turn: utilization is the goal. Hence, the dissemination process should be interactive, allowing feedback from receiving audiences according to a cyclical model of communications flow as the one shown in Figure 10.

C.5.3.i. Traditional Approaches: Our findings will be disseminated to a broad audience including: 1) frontline clinicians, 2) clinical leadership and managerial decision makers 3) health systems, and 4) policy decision makers at the local, network, and national levels. We will also submit manuscripts to different peer- reviewed medical, informatics, patient safety, public health, and health services journals and present at regional and national conferences. We will leverage our professional membership and participation on national committees to disseminate our work to experts in the field. We will also plan to write blog posts placed on Nova Southeastern University digital outlets.

C.5.3.ii. Integration into Existing Practices, Scalability, and Sustainability: Beyond traditional channels for sharing research results – publications, conferences, design and maintenance of a dedicated web site where information, instrumentation, models, tools, approaches, and data about the study will be posted – designing materials to support what we know to be the most successful mechanism for diffusing knowledge and ensuring implementation success: peer-to-peer, physician-to-physician, educational experiences and programs. One of the most effective channels for adoption of innovation is peer-to-peer education. The KC Patel College of Allopathic Medicine will develop and offer a series of innovative peer-to-peer educational workshops and programs (generating CME units) designed to disseminate successful interventions uncovered and tested in this research. While we will start offering these

Figure 10: Dissemination Elements

Table 7: Sample Outcomes and Effectiveness Measures and Sources

programs in South Florida, we will quickly expand nationally, working with partners. As part of Aim 3, we will develop and create usable guidelines, roadmaps, process flow maps, simulation tools, and other toolkits that can be used by healthcare systems.

C.5.3.iii. Development of a Virtual Consortium for Dissemination: We will not only report results but actually develop assessment tools, training materials, methodologies that can be shared and/or taught. We will work with AHRQ staff to contact all other grantees and their health systems partners, establish a virtual consortium, add their ideas to the mix and bring bundles of practices to bear. The virtual consortium will start during the grant work and will continue to operate after funding. We will continue to review published studies of best practices and lessons learned. We will apply for a conference grant from AHRQ and hold a conference with other grantees. We will publish all best papers as a special issue on best practices in HCA Healthcare Journal of Medicine (Jacko, who is serving on the Editorial Board, will serve as a special editor).

D. HUMAN SUBJECTS INVOLVEMENT, PROTECTION AND PRIORITY POPULATIONS

We will obtain IRB approval to conduct this project. There are no major risks associated with participating in this study and no immediate potential benefits for participants. For Aims 1 and 2, recruitment is voluntary. We will obtain informed consent from key informants. Clinical and organizational data will be completely de-identified and processed by HCA data analytics group. As detailed in the proposal, the South Florida population is highly diverse and vulnerable and thus we will be evaluating the response of a large health system to optimize delivery of health care for priority populations including low-income groups, minority groups, women and the elderly.

E. POTENTIAL PITFALLS AND ALTERNATE STRATEGIES

While we have significant experience with similar projects and methods, we have developed mitigation strategies to prepare for any potential barriers. First, based on our prior experience, we anticipate encountering some difficulties in recruiting providers/facility staff and patients and might encounter some delays. However, having dedicated site champions and site research associates will allow us to overcome these barriers. Second, because of the uniqueness of HCA Healthcare as a partner, some results may not be fully generalizable. However, as part of Aim 1, we will ensure that HCA-specific factors are identified and the research team will derive and articulate more generic alternatives or variations of the organizational practices that can be applicable to other systems, or note that some of these practices my need to be modified to suit a different setting.

F. TIMELINE The timeline is shown in Figure 11. Upon notice of award, all participants will process data use agreements, institutional review board approval, and intellectual property agreements. Hiring logistics will include postdocs. Internal staff are available to ensure timely hiring and onboarding of any additional needed personnel.

Figure 11: Overall Project Timeline

CRITICAL THINKING 5

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Ethical Decision-Making and Reasoning: Ethical Reasoning and Analysis

Ethical Reasoning and Analysis

This resource deals with the following ques!ons about ethical reasoning:

1. What is meant by ethics?

2. What is not ethics?

3. What does it mean to be ethical?

4. Do ethical and moral mean the same thing?

5. What are values?

6. What are some examples of ethical issues?

7. How can I effec!vely apply cri!cal reasoning to an ethical issue?

8. When I debate ethical issues, what is my responsibility to people who are part of the dialogue?

9. What are ethical judgments?

10. How can I dis!nguish ethical judgments from other kinds of value judgments?

11. What are ethical arguments?

12. What is an ethical dilemma?

13. What is the role of values in ethical dilemmas?

14. What ethical dilemmas are more common in real life?

15. What is an ethical viola!on?

16. How does self-interest affect people's ethical choices?

17. What is the difference between good ethical reasoning and mere ra!onaliza!on?

18. What kinds of ra!onaliza!ons do people make for their ac!ons?*

19. What fallacies are most prevalent in debates over ethical issues?

20. How can I tell what is the "right" thing to do?

21. What is moral rela!vism?

22. What is the main weakness of moral rela!vism?

23. What is universalism?

24. What is consequen!alism?

Learning Resource

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25. What is u!litarianism?

26. How does u!litarian reasoning operate?

27. How has u!litarian reasoning been applied?

28. What is the main weakness of u!litarianism?

29. How do I apply u!litarianism in real life?

30. What is deontology?

31. What is duty-based ethics?

32. What is rights-based ethics?

33. What is the appeal of deontology?

34. What is the main weakness of duty and rights-based ethics?

35. How can I apply deontology in real life?

36. What is virtue ethics?

37. What is care ethics?

38. How does virtue ethics operate?

39. What kinds of ques!ons are asked by virtue ethics?

40. How has virtue ethics been applied in the real world?

41. What is the main weakness of virtue ethics?

42. How can I apply virtue ethics in real life?

43. How do these theories fit into my ethics toolbox?

44. How do I use ethical reasoning to make decisions?

45. How do I recognize an ethical situa!on?

46. How do I iden!fy stakeholders?

47. How do I iden!fy the different perspec!ves and posi!ons held by stakeholders?

48. How can I research stakeholder posi!ons?

49. How do I iden!fy the ethical actor?

50. How can I use cri!cal thinking in this process?

51. What are criteria?

52. How do I iden!fy possible ac!ons?

53. How do I evaluate the possible op!ons?

54. How can mapping or diagramming help me to examine the consequences of decisions or posi!ons with

ethical consequences?

55. What else should I consider before ac!ng?

56. Am I done a#er ac!ng?

57. Do people really do all this when making ethical decisions?

1. What is meant by ethics?

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Ethics is the study of the standards of right and wrong that inform us as to how we ought to behave. These

standards relate to unwri$en rules that are necessary for humans to live amongst each other, such as "don't

hurt others." We func!on be$er as a society when we treat each other well.

Ethics can also refer to the standards themselves. They o#en pertain to rights, obliga!ons, fairness,

responsibili!es, and specific virtues like honesty and loyalty.

They are supported by consistent and well-founded reasons; as such, they have universal appeal. It's never

good to have a society that supports hur!ng others as a general rule; honesty and loyalty are posi!ve

a$ributes.

Can we think of instances when hur!ng others is condoned (such as in war) and where honesty or loyalty

may be misplaced? Of course! That's one of the reasons why ethics are so complicated.

2. What is not ethics?

We need to dis!nguish ethics from what it is not. It's easier if you can remember that ethics doesn't change:

Ethics is not what's legal. The law o#en puts into wri!ng our ethical standards (don't hurt others=don't

commit homicide) but it also usually reflects our cultural beliefs at the !me. For example, hun!ng is

legal in Virginia, but it would be difficult to say that everyone agrees that it is ethical to hunt. Some

people will argue that hun!ng is ethical because it manages the wildlife popula!on, while others will

argue that it is never ethical because it creates pain and suffering.

Ethics is not what you feel. In fact, most !mes our feelings are very egocentric: what's best for me and

my nearest and dearest? But making judgments based on these sen!ments could be detrimental to

society as a whole,

Ethics is not religion. Religions may teach ethical standards, and you may personally use religion to

guide your beliefs, but people can have ethics without necessarily belonging to a religion. Therefore,

ethics and religion are not interchangeable.

Ethics is not a poli!cal ideology. A poli!cal party may share your values and offer ethical arguments to

supports its policies, but your decisions aren't automa!cally ethical, just because you belong to one

poli!cal party or another. In fact, many, if not most, poli!cal debates are built from arguments that

claim one aspect of an ethical dilemma is more significant than another.

3. What does it mean to be ethical?

When we explore what it means to be ethical, we are looking at what is ra!onally "right" and "wrong." We

need to have such conversa!ons so that we can live with other people in society. Philosophers would also

argue that the best way to achieve our fullest poten!al is by being ethical.

In this course, we are not teaching you what to believe. We are building on the skills you have learned to

iden!fy, evaluate, create and analyze ethical arguments.

4. Do ethical and moral mean the same thing?

For the purposes of this handbook, the answer is yes. The terms ethical and moral are o#en used as

synonyms, and we will adopt this conven!on and use these terms interchangeably. For most purposes this

works fine, but some authors and teachers do see a dis!nc!on between these ideas. Usually when the

terms are dis!nguished it is because morals can connote very culture-specificnormsor expecta!ons. Hence

"the mores of the Azande" describes the moral norms of that par!cular tribe or culture, but without

expecta!on that these norms are universally valid. When ethics is contrasted with morals, the writer is

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usually discussing certain norma!ve ethical theories that maintain that certain principles, rules, or virtues

have universal ethical validity. A slightly more comprehensive answer would describe the difference; say

from an ethical rela!vist posi!ons defini!on, as hinging on ethical standards being subjected to the scru!ny

of reason or ra!onality as its fundamental method.

5. What are values?

Frequently when used in discussions of ethics the termvaluesis used to refer to the fundamental ideals that

an individual relies on to describe praise-worthy behavior. A person's values are the bedrock concepts used

to determine their ethical decisions. Most generally speaking values represent aspira!onal goals common

within your culture or society. Values such as honesty, benevolence, wisdom, duty, or compassion are

universally recognized laudable and desirable features of a well-developed character. But which values are

most important may differ from individual to individual, or across cultures. We could refer to the values of

the feudal Japanese samurai culture placing the highest emphasis on the concept of personal honor. We

could compare and contrast that with the European knightly virtues as a similar yet dis!nc!vely different set

of cultural values. We could draw on poli!cal beliefs to describe the concepts of equality and freedom at the

heart of democra!c ideals, contras!ng them with a cons!tu!onal monarchy that perhaps places the highest

importance on duty and tradi!on as its central poli!cal ideals

6. What are some examples of ethical issues?

Ethical issues abound in contemporary society. Ethical issues involve ques!ons of the ethical rightness or

wrongness of public policy or personal behavior. Ac!ons or policies that affect other people always have an

ethical dimension, but while some people restrict ethical issues to ac!ons that can help or harm others

(social ethics) others include personal and self-regarding conduct (personal ethics).

Many of today's most pressing issues of social ethics are complex and mul!faceted and require clear and

careful thought. Some of these issues include the following:

Should states allow physician-assisted suicide?

Is the death penalty an ethically acceptable type of punishment?

Should animals have rights?

Is society ever jus!fied in regula!ng so-called vic!mless crimes like drug use, not wearing a helmet or a

seatbelt, etc.?

What are our responsibili!es to future genera!ons?

Are affluent individuals and countries obligated to try to prevent starva!on, malnutri!on, and poverty

wherever we find them in the world?

Is there such a thing as a just war?

How does business ethics relate to corporate responsibility?

To reach careful conclusions, these public policy issues require people to engage in complicated ethical

reasoning, but the ethical reasoning involving personal issues can be just as complex and mul!faceted:

What principles do I apply to the way I treat other people?

What guides my own choices and my own goals in life?

Should I have the same expecta!ons of others in terms of their behavior and choices as I have of

myself?

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Is living ethically compa!ble or incompa!ble with what I call living well or happily?

7. How can I effec!vely apply cri!cal reasoning to an ethical issue?

People care quite a bit about ethical issues and o#en voice varied and even sharply opposed perspec!ves.

So when looking at how we debate ethical issues publicly, it is not surprising to find debate ranging from

formal to informal argumenta!on, and from very carefully constructed arguments with well-qualified

conclusions, to very biased posi!ons and quite fallacious forms of persuasion. It's easy to be dismayed by

the discord we find over vola!le issues like gun control, immigra!on policy, equality in marriage or in the

workplace, gender and racial equality, abor!on and birth control, freedom versus security, free speech and

censorship, and so on. But it is also easy to go the other direc!on and be drawn into the o#en fallacious

reasoning we hear all around us.

Cri!cal thinkers want to conduct civil, respec'ul discourse, and to build bridges in ways that allow progress

to be made on difficult issues of common concern. Progress and mutual understanding is not possible when

name-calling, inflammatory language, and fallacies are the norm. Some mutual respect, together with the

skill of being able to offer a clearly-structured argument for one's posi!on, undercuts the need to resort to

such tac!cs. So cri!cal thinkers resist trading fallacy for fallacy, and try to introduce common ground that

can help resolve disputes by remaining respec'ul of differences, even about issues personally quite

important to them. When we support a thesis (such as a posi!on on one of the above ethical issues) with a

clear and well-structured argument, we allow and invite others to engage with us in more construc!ve

fashion. We say essen!ally, "Here is my thesis and here are my reasons for holding it. If you don't agree with

my claim, then show me what is wrong with my argument, and I will reconsider my view, as any ra!onal

person should."

8. When I debate ethical issues, what is my responsibility to people who are part of the dialogue?

When we evaluate (analyze) somebody else's posi!on on an ethical issue, we are not free to simply reject

out-of-hand a conclusion we don't ini!ally agree with. To be reasonable, we must accept the burden of

showing where the other person errs in facts or reasoning. If we cannot show that there are errors in the

person's facts or reasoning, to be reasonable we must reconsider whether we should reject the other

person's conclusion.

By applying the common standards of cri!cal thinking to our reasoning about ethical issues, our arguments

will become less emo!onally driven and more ra!onal. Our reasoning will become less dependent upon

unques!oned beliefs or assump!ons that the other people in the conversa!on may not accept. We become

be$er able to contribute to progressive public debate and conflict resolu!on through a well-developed

ability to ar!culate a well-reasoned posi!on on an ethical issue.

9. What are ethical judgments?

Ethical judgments are a subclass of value judgments. A value judgment involves an argument as to what is

correct, superior, or preferable. In the case of ethics, the value judgment involves making a judgment, claim,

or statement about whether an ac!on is morally right or wrong or whether a person's mo!ves are morally

good or bad. Ethical judgments o#en prescribe as well as evaluate ac!ons, so that to state that someone (or

perhaps everyone) ethically "should" or "ought to" do something is also to make an ethical judgment.

10. How can I dis!nguish ethical judgments from other kinds of value judgments?

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If ethical judgments are a subclass of value judgments, how do we dis!nguish them? Ethical judgments

typically state that some ac!on is good or bad, or right or wrong,in a specifically ethical sense. It is usually

not difficult to dis!nguish nonethical judgments of goodness and badness from ethical ones. When

someone says "That was a good ac!on because it was caring," or "That was bad ac!on because it was cruel,"

they are clearly intending goodness or badness in a dis!nctly ethical sense.

By contrast, nonmoral value judgments typically say that something is good (or bad) simply for the kind of

thing it is, or we say that some ac!on is right or wrong given the prac!cal goal or purpose that one has in

mind. "That's a good car" or "That's a bad bike" would not be considered to moral judgments about those

objects. Goodness and badness here are s!ll value judgments, but value judgments that likely track features

like comfort, styling, reliability, safety and mileage ra!ngs, etc.

The use of "should" or" ought to" for nonmoral value judgments is also easy to recognize. "You ought to

enroll early" or "You made the right decision to go to Radford" are value judgments, but no one would say

they are ethical judgments. They reflect a concern with wholly prac!cal aims rather than ethical ones and

with the best way to a$ain those prac!cal aims.

11. What are ethical arguments?

Ethical arguments are arguments whose conclusion makes an ethical judgment. Ethical arguments are most

typically arguments that try to show a certain policy or behavior to be either ethical or unethical. Suppose

you want to argue that "The death penalty is unjust (or just) punishment" for a certain range of violent

crimes. Here we have an ethical judgment, and one that with a bit more detail could serve as the thesis of a

posi!on paper on the death penalty debate.

An ethical judgment rises above mere opinion and becomes the conclusion of an ethical argument when you

support it with ethical reasoning. You must say why you hold the death penalty to be ethically right or

wrong, just or unjust. For instance, you might argue that it is unjust because of one or more of the following

reasons:

It is cruel, and cruel ac!ons are wrong.

Two wrongs don't make a right.

It disrespects human life.

In some states the penalty falls unevenly on members of a racial group.

The penalty some!mes results in the execu!on of innocent people.

Of course, you could also give reasons to support the view that the death penalty is a just punishment for

certain crimes. The point is that whichever side of the debate you take, your ethical argument should

develop ethical reasons and principles rather than economic or other prac!cal but nonmoral concerns. To

argue merely that the death penalty be abolished because that would save us all money is a possible policy

posi!on, but it is essen!ally an economic argument rather than an ethical argument.

12. What is an ethical dilemma?

An ethical dilemma is a term for a situa!on in which a person faces an ethically problema!c situa!on and is

not sure of what she ought to do. Those who experience ethical dilemmas feel themselves being pulled

by compe!ng ethical demands or values and perhaps feel that they will be blameworthy or experience guilt

no ma$er what course of ac!on they take. The philosopher Jean-Paul Sartre gives the example of a young

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Frenchman of military age during the war!me Nazi occupa!on who finds himself faced, through no fault of

his own, with the choice of staying home and caring for his ailing mother or going off to join the resistance

to fight for his country's future:

He fully realized that this woman lived only for him and that his disappearance—or perhaps his death—

would plunge her into despair... Consequently, he found himself confronted by two very different

modes of ac!on; the one concrete, immediate, but directed towards only one individual; and the other

an ac!on addressed to an end infinitely greater, a na!onal collec!vity, but for that very reason

ambiguous—and it might be frustrated on the way (Sartre, 1946).

13. What is the role of values in ethical dilemmas?

Frequently, ethical dilemmas are fundamentally a clash of values. We may experience a sense of frustra!on

trying to figure out what the "right" thing to do is because any available course of ac!on violates some value

that we are dedicated to. For example, let's say you are taking a class with a good friend and si(ng next to

him one day during a quiz you discover him copying answers from a third student. Now you are forced into

an ethical decision embodied by two important values common to your society. Those values are honesty

and loyalty. Do you act dishonestly and preserve your friend's secret or do you act disloyal and turn them in

for academic fraud?

Awareness of the underlying values at play in an ethical conflict can act as a powerful method to clarify the

issues involved. We should also be aware of the use of value as a verb in the ethical sense. Certainly what

we choose to value more or less will play a very significant role in the process of differen!a!ng between

outcomes and ac!ons thereby determining what exactly we should do.

Literature and film are full of ethical dilemmas, as they allow us to reflect on the human struggle as well as

presen!ng tests of individual character. For example in World War Z, Gerry Lane (played by Brad Pi$ in the

movie version) has to make a similar choice as Sartre's Frenchman: between serving the world-community of

humans in their just war against zombies, and serving his own immediate family. It adds depth and

substance to the character to see him struggling with this choice over the right thing to do.

14. What ethical dilemmas are more common in real life?

Rarely are we called on to fight zombies or Nazis, but that doesn't mean we live in an ethically easy world. If

you've ever felt yourself pulled between two moral choices, you've faced an ethical dilemma. O#en we

make our choice based on which value we prize more highly. Here are some examples:

You are offered a scholarship to a$end a far-away college, but that would mean leaving your family, to

whom you are very close. Values: success/future achievements/excitement vs. family/love/safety

You are friends with Jane, who is da!ng Bill. Jane confides in you that she'd been seeing Joe on the side

but begs you not to tell Bill. Bill then asks you if Jane has ever cheated on him. Values:

Friendship/loyalty vs. Truth

You are the official supervisor for Tywin. You find out that Tywin has been leaving work early and asking

his coworkers to clock him out on !me. You intend to fire Tywin, but then you find out that he's been

leaving early because he needs to pick up his child from daycare. Values: Jus!ce vs. Mercy

You could probably make a compelling argument for either side for each of the above. That's what makes

ethical dilemmas so difficult (or interes!ng, if you're not directly involved!).

15. What is an ethical viola!on?

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Some!mes we are confronted with situa!ons in which we are torn between a right and a wrong; we know

what the right thing to do would be, but the wrong is personally beneficial, temp!ng, or much easier to do.

In 2010, Ohio State University football coach Jim Tressel discovered that some of his players were viola!ng

NCAA rules. He did not report it to anyone, as it would lead to suspensions, hur!ng the football team's

chances of winning. He was not torn between two moral choices; he knew what he should do, but didn't

want to jeopardize his career. In 2011, Tressel's unethical behavior became public, OSU had to void its wins

for the year, and he resigned as coach (Livingston, 2011).

Ethics experts tend to think that ethical considera!ons should always trump personal or self-interested ones

and that to resist following one's personal desires is a ma$er of having the right mo!va!on and the strength

of will to repel tempta!on. One way to strengthen your "ethics muscles" is to become familiar with the ways

we try to excuse or dismiss unethical ac!ons.

16. How does self-interest affect people's ethical choices?

In a perfect world, morality and happiness would always align: living ethically and living well wouldn't collide

because living virtuously—being honest, trustworthy, caring, etc.—would provide the deepest human

happiness and would best allow humans to flourish. Some would say, however, that we do not live in a

perfect world, and that our society en!ces us to think of happiness in terms of status and material

possessions at the cost of principles. Some even claim that all persons act exclusively out of self-interest—

that is, out of psychological egoism—and that genuine concern for the well-being of others—altruism—is

impossible. As you explore an ethical issue, consider whether people making choices within the context of

the issue are ac!ng altruis!cally or out of self-interest.

17. What is the difference between good ethical reasoning and mere ra!onaliza!on?

When pressed to jus!fy their choices, people may try to evade responsibility and to jus!fy decisions that

may be unethical but that serve their self-interest. People are amazingly good at passing the buck in this

fashion, yet pre$y poor at recognizing and admi(ng that they are doing so. When a person is said to be

ra!onalizing his ac!ons and choices, this doesn't mean he is applying cri!cal thinking, or what we have

described as ethical analysis. Quite the opposite: it means that he is trying to convince others—or o#en just

himself—using reasons that he should be able to recognize as faulty or poor reasons. Perhaps the most

common ra!onaliza!on of unethical ac!on has come to be called the Nuremberg Defense: "I was just doing

what I was told to do—following orders or the example of my superior. So blame them and exonerate me."

This defense was used by Nazi officials during the Nuremberg trials a#er World War II in order to ra!onalize

behavior such as par!cipa!on in the administra!on of concentra!on camps. This ra!onaliza!on didn't work

then, and it doesn't work now.

18. What kinds of ra!onaliza!ons do people make for their ac!ons?

Ra!onaliza!on is a common human coping strategy. An intriguing finding in research on corrup!on is that

people who behave unethically usually do not see themselves as unethical. Instead, they recast their ac!ons

using ra!onaliza!on techniques to jus!fy what they've done. Common ra!onaliza!on strategies:

Denial of responsibility

The people engaged in bad behavior "had no choice" but to par!cipate in such ac!vi!es OR people

turn a blind eye to ethical misbehavior.

Examples:

"What can I do? My boss ordered me not to tell the police."

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"My neighbors' children always seem to have bruises, but it's none of my business."

Denial of injury

No one is harmed by the ac!on, or that the harm could have been worse.

Examples:

"All's well that ends well."

"Nobody died."

Blaming the vic!m

Counter any blame for the ac!ons by arguing that the violated party deserved what happened.

Examples:

"She chose to go that fraternity party; what did she think was going to happen?"

"If the professors don't want students to say mean things in student evalua!ons, they should

be more entertaining."

Social weigh!ng

Compared to what other people have done, this is nothing, OR everybody does it, so it's okay.

Examples:

"I some!mes come into work late, but compared to everybody who leaves early every Friday,

it's nothing to get worked up over."

"Everyone around me was tex!ng; it's not fair that I should be the one in trouble."

Appeal to higher values

It was done for a good, higher cause.

Examples:

"You should let me copy your homework; if I fail this class, I'll lose my scholarship."

"I couldn't tell anyone because I'm loyal to my boss."

Saint's excuse

If someone has done good things in the past, they should get a "pass" for misbehavior.

Examples:

"He's done so many good things for the community, it would be a shame to punish him."

"She's so talented, why focus on the bad things she's done?" (Anand, Ashforth, & Joshi, 2004).

19. What fallacies are most prevalent in debates over ethical issues?

In addi!on to self-decep!on and ra!onaliza!ons, we o#en find overtly fallacious reasoning that undermines

open, construc!ve debate of ethical issues. Of the common fallacies, those most common in ethics debate

include ad hominem (personal) a$acks, appeals to false authority, appeals to fear, the slippery

slope fallacy, false dilemmas, the two-wrongs-make-a-right fallacy, and the strawman fallacy (Core

Curriculum, "Core 201—The Logical Structure of Arguments," 2016). Fallacious reasoning, especially the

a$empt to sway sen!ment through language manipula!on, is ever-present in popular sources of informa!on

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and opinion pieces, like blogs and special-interest-group sites. It may take prac!ce to spot fallacious

reasoning, but being able to give names to these strategies of trickery and manipula!on provides the

aspiring cri!cal thinker with a solid start.

20. How can I tell what is the "right" thing to do?

That's the million-dollar ques!on here. Ethical theories describe the rules or principles that guide people

when the rightness or wrongness of an ac!on becomes an issue. In this sec!on, you will read about some of

the most common and important ways of approaching ethics. They all ask the ques!on "How can I tell what

the right thing to do is?" but differ as to where to start and what to consider:

1. Situa!on. Rela!vists say that rightness changes depending on the individuals and culture involved.

2. Results. Consequen!alists believe that you should judge rightness based on the predicted outcome.

U!litarianism is a type of consequen!alist perspec!ve.

3. Ac!ons. Deontologists judge the rightness purely on the ac!on itself. Duty-based and rights-based

perspec!ves fall into this category.

4. Actors. In actor-oriented perspec!ves, the person or en!ty making the decision—the ethical actor—

must decide what a virtuous person or en!ty would do, and follow that path. The ethical actor may also

be called the agent.

Next, we'll learn more about each perspec!ve and its challenges and benefits.

21. What is moral rela!vism?

Moral rela!vism rejects the view that there are universal and never-changing ethical standards that can

always be used to judge whether ac!ons are right and wrong. Instead, a moral rela!vist might argue that

ethical judgments are made within the context of a culture and !me period. People in one culture or !me

period may judge an ac!on to be ethical; people in another culture or !me period may judge the same

ac!on to be unethical.

Some moral rela!vists even reject the no!on that cultures determine what is right and wrong. Instead, these

moral rela!vists argue that each individual must develop his or her own standards for determining what is

ethical. These standards might be based on reason or on intui!on, something like a gut feeling that an ac!on

is ethical.

People may be drawn to moral rela!vism because it appears to be a tolerant view. They may feel that

adop!ng moral rela!vism will eliminate the conflicts that may arise between people and cultures that reach

different conclusions about what is right or wrong.

22. What is the main weakness of moral rela!vism?

Moral rela!vism may be embraced by people who value tolerance. However, you could argue that a moral

rela!vist who treats tolerance as something that is unques!onably good has actually abandoned moral

rela!vism. Cri!cs of moral rela!vism some!mes ask this ques!on: Is it logically possible to be a moral

rela!vist and to simultaneously behave as if tolerance is a universal value?

Another apparent contradic!on may arise when an individual's (or culture's) right to decide what is ethical

runs up against another individual's (or culture's) right to do the same. This paradox can be illustrated by

looking at The Universal Declara!on of Human Rights (United Na!ons, 1948). This document was approved

by the United Na!ons a#er World War II. Near its beginning, it states that "All human beings are born free

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and equal in dignity and rights" (United Na!ons, 1948). With this statement as a star!ng point, a number of

principles follow: a universal right to be safe from enslavement, for example, or a universal right to

educa!on regardless of gender.

Taken as a whole, the Declara!on argues that people have autonomy: the freedom to act in their own

interests.

However, if what is right is whatever a culture determines to be right, then slavery is ethical in a slave-

owning society or household. If what is right is whatever an individual determines to be right, then denying

a girl access to educa!on is ethical in a household whose head believes it is inappropriate for girls to be

educated.

On the one hand, then, moral rela!vism does not impose value systems on people. On the other hand, it

seems to grant humans autonomy—the freedom to act in one's own interest—to people who would deny

that autonomy to other people.

23. What is universalism?

Imagine that there is one never-changing and universal set of standard for deciding whether an ac!on is

ethical. That approach to judging behavior is calleduniversalism. A person who follows this approach

believes that guidelines for judging behavior are not affected by !me and culture. What is right is always

right, and what is wrong is always wrong—without excep!on and everywhere in the world.

Consequen!alism and deontology are universalist ethical theories.

24. What is consequen!alism?

Consequen!alists believe that an ac!on is right or wrong depending on the results of the ac!on. The act

itself ma$ers less than whether the effects are posi!ve or nega!ve. So for a consequen!alist, no type of act

is inherently wrong. The ethically right choice is the one that has the best overall consequences.

In addi!on, the more good consequences that occur from an act, the be$er or more ethical that act should

be judged.

25. What is u!litarianism?

U!litarianism is a specific type of consequen!alism that focuses on the greatest good for the greatest

number. A#er you iden!fy your op!ons for ac!on, you ask who will benefit and who will be harmed by

each. The ethical ac!on would be the one that caused the greatest good for the most people, or the least

harm to the least number.

26. How does u!litarian reasoning operate?

Early u!litarian thinkers sought to "scien!ze" ethical decision-making. They developed a "calculus"

comparable to a modern cost/benefit analysis. This calculus weighed the consequences of an ac!on in

terms of its impact on all the sen!ent beings that might be affected. Sen!ent beings feel pain or pleasure, so

the calculus could consider the effect an ac!on might have on animals as well as humans.

The calculus took into account several factors, such as

the number of humans and animals that would benefit,

the number of humans and animals that would be harmed,

how intense any resul!ng pleasure would be,

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how long any resul!ng pleasure might last,

how intense any resul!ng pain would be, and

how long any resul!ng pain might last.

While such a calculus for resolving ethical problems may seem idealized, u!litarian thinking coincided with a

genuine desire to eliminate unnecessary suffering through seeking to answer the ques!on," Which op!on

will serve the greater good?"

U!litarianism stressed equality and fights against self-interest on the part of the ethical actor. As an

illustra!on, let's say you've volunteered to buy the paint for the fence that you and your three bordering

neighbors share. The fence has to be painted one color: brown or white. You prefer white but your

neighbors want brown. If you used a u!litarian approach, you would buy brown paint because three

outnumbers one. Just because you are buying the paint does not give you any more weight in the decision.

27. How has u!litarian reasoning been applied?

U!litarian thinking led to many reforms. It helped bring an end to the mistreatment of animals, orphans, and

child laborers, as well as to the harsh treatment of adult laborers, prisoners, the poor, and the mentally ill. It

provided arguments for abolishing slavery and for elimina!ng inequali!es between the sexes. For John

Stuart Mill, one of the founders of the theory, both logic and morality dictated that one person's happiness

should count as much as another person's happiness. This principle was applied to people whether they

were wealthy or poor, powerful or weak.

Today few people think an ethical calculus can tell us exactly how compe!ng interests should be weighed.

But the more general u!litarian approach to ethical reasoning is s!ll immensely influen!al. The principle that

each person's happiness should be as important as any other person's happiness requires a society to make

decisions in which the interests of all its members are considered in a balanced, ra!onal fashion.

We can see u!litarianism in ac!on in many public health efforts. For example, children in public schools are

required to receive certain vaccina!ons. This is mandatory because of the results: keeping people healthy

and the greater good: individuals may object to the vaccina!ons, but the law focuses on the greater good

for the greatest number.

28. What is the main weakness of u!litarianism?

The u!litarian principle says that people should act to promote overall happiness, but this principle appears

to jus!fy using people in ways that do not respect the idea that individual rights may not be violated. That

is, the u!litarian approach seems to imply that it would be ethical to inflict pain on one person if that ac!on

results in a net increase in happiness.

Here is a classic ques!on that is posed to expose this poten!al weakness in the u!litarian approach to

ethical reasoning: Why not kill and harvest the organs of one healthy person in order to save five pa!ents

who will go on to live happy lives?

The philosopher William James argued that it would be a "hideous… thing" if "millions [were] kept

permanently happy on the one simple condi!on that a certain lost soul on the far-off edge of things should

lead a life of lonely torture," but that situa!on would seem consistent with u!litarianism (James, 2000, pp.

244–245).

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James's scenario inspired a short story by Ursula Le Guin, "Those Who Walk Away from Omelas," in which

the happiness of a society depends upon the suffering of one child. Some members of this society are

unable to live with this fact and "walk away from Omelas" (Le Guin, 1973).

U!litarian's emphasis on consequences can also be a weakness. That emphasis can lead to "all's well that

ends well" thinking, allowing people to jus!fy immoral acts if the outcome is beneficial. One must also ask,

can we ever be sure of the consequences of our ac!ons? If we take an ac!on that we expected would have

good consequences, but it ends up harming people, have we behaved unethically regardless of our

inten!ons?

29. How do I apply u!litarianism in real life?

When faced with an ethical dilemma, ask yourself:

1. Which op!on would have be$er results?

2. Which op!on would further the greater good?

3. How can I maximize benefits for all involved?

4. How can I minimize suffering for all involved?

30. What is deontology?

Deontology is a universal ethical theory that considers whether an ac!on itself is right or wrong.

Deontologists argue that you can never know what the results will be so it doesn't make sense to decide

whether something is ethical based on outcomes. You can consider it the opposite of consequen!alism and

u!litarianism in many ways.

Deontologists live in world of moral rules: It is wrong to steal. It is right to keep promises.

Deontology is also concerned with inten!ons. If you intended good through your ac!on, then the ac!on is

good, no ma$er what actually happened as a result.

Deontology encompasses two kinds of approaches: duty-based and rights-based.

31. What is duty-based ethics?

Duty-based ethics says that there are universal moral norms or rules, and it is essen!al that everyone

follows them. If you've ever said, "I did it because it was the right thing to do," then you've employed duty-

based ethics.

Duty-based ethics maintains that you should follow an ethical code without considering the consequences

of your ac!ons. If an act is by its nature right, you should perform that act even if someone is harmed as a

result. If an act is by its nature wrong, you should not perform that act even if someone might be helped. For

example, if by defini!on stealing is wrong, you do not steal. If by defini!on lying is wrong, you do not lie.

When you think about du!es, think about obliga!ons that individuals must accept in order for society to

work and be well. Your du!es and obliga!ons come from both your personal and professional lives. If you

are a parent, you are obligated to take care of your children. If you see someone in distress, you have a duty

as a human to try and help.

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The du!es themselves may be !ed to professional roles, too. Teachers have a duty to grade students fairly;

police officers have a duty to enforce the law; psychologists have a duty to respect the confiden!ality of

their pa!ents. When you encounter codes of professional conduct—either wri$en or unwri$en—likely you

are dealing with duty-based ethics.

32. What is rights-based ethics?

An outgrowth of duty-based ethics, rights-based ethics insists that you need to respect individual's human

rights and never treat people as a means to an end.

A right is something you are en!tled to. In terms of ethics, it is the treatment you should be able to expect

from other people. For example, under most ethical codes, as a human you are en!tled—have a right—to

exist in safety.

Another way of sta!ng this idea is that you have a right not be harmed by anyone. When the idea is put that

way, it is apparent that du!es and rights are closely related concepts. You have a right to exist in safety,

which means that other people have a duty not to harm you.

Since du!es and rights are so closely related, a version of a duty-based ethics can be created by iden!fying

the rights that someone has a duty to respect.

Rights-based ethics are built upon four claims. Rights are

"natural insofar as they are not invented or created by governments;"

"universal insofar as they do not change from country to country;"

"equal in the sense that rights are the same for all people, irrespec!ve of gender, race, or handicap;"

and

"inalienable which means that I cannot hand over my rights to another person, such as by selling myself

into slavery." (Fieser, n.d.)

A noteworthy example of an argument grounded in rights-based ethics is found in the Declara!on of

Independence, where Thomas Jefferson states that humans are "endowed by their Creator with certain

unalienable rights, that among these are Life, Liberty and the pursuit of Happiness" (Jefferson, 1776). By

drawing a$en!on to these rights, Jefferson provides the context for a lengthy list of the ways in which

George III had not fulfilled his duty to uphold these rights.

Remember that deontology is a universal system, so that means any rights that you claim you also have to

grant to all others. If you believe your family has a right to drinking water, then this means everyone in the

world has that same right. If you believe that you have a right to marry the person you choose, then so does

everyone else.

33. What is the appeal of deontology?

As we discussed in u!litarianism, a flaw with consequen!alist thinking is that we can never really know what

the results of an ac!on will be. History is full of examples of "unintended consequences." For example, in an

a$empt to raise standards and accountability in public schools, high-stakes tes!ng became common. To

ensure that the tests were taken seriously, school districts held teachers responsible for their students'

scores; teachers whose students did well would get raises, while those who did poorly could be fired. The

proponents of this policy predicted that children's learning would improve. It seemed to be working: in

Atlanta; students were showing extraordinary gains in the yearly competency tests. Then an inves!ga!on by

the Atlanta Journal-Cons!tu!on revealed that teachers and principals were correc!ng the answers provided

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by students. This scandal rocked the Atlanta school system and as of 2015, 11 teachers were convicted on

racketeering charges. This certainly is not what the high-stakes tes!ng supporters had thought would

happen!

Because of such examples, deontologists disdain the uncertainty of consequen!alist ethics. The future is

unpredictable; we should only make judgments on things we are certain about. We know whether an ac!on

is inherently right or wrong as we're doing it.

Another good point about deontology is its emphasis on the value of every human. While u!litarians

consider everyone equal, it's more of a numbers game. But a deontologist insists that you treat everyone

with respect and give everyone the rights you expect to have yourself. It works against our tendency to be

self-centered.

Finally, deontology gives credit for inten!ons and mo!va!ons. You may do something for the very best

reasons and it could turn out nega!vely. Does that condemn your ac!on as unethical? A deontologist would

say no. Accidents happen, results are uncertain, and you can't be held responsible for the future.

34. What is the main weakness of duty and rights-based ethics?

Both duty and rights-based ethics are forms of universalism because they rely on principles that must be

applied at all !mes to all people. Some people object that the universalism of duty and rights-based ethics

make these theories too inflexible.

Both also rely on absolute principles regarding du!es and rights. But there's no defini!ve list recorded

anywhere. One person might say parents have a right to spank their children, but others will disagree. In the

case of duty-based ethics, people may object to the principle that people deciding on a course of ac!on

should ignore the circumstances in which they and other individuals find themselves. Duty ethics allows

li$le room for context. In Les Misérables, was Jean Valjean wrong to steal bread to feed his starving sister's

children (Hugo, 1887)? Would it have been wrong to lie to a Gestapo officer asking where Jews were hidden

or to slave-catchers in pursuit of runaways in the pre-war South? Some would say that the answers depend

upon the circumstances and op!ons available to us, rather than on it being the case that certain types of

ac!ons are always and necessarily wrong.

Duty-based ethics accepts as a principle that one should never use another person merely as a means to

someone else's ends. So it would never be jus!fied to cause the death of one to save several. But is that

ac!on always wrong, as a duty ethicist would argue? Socie!es regularly sacrifice individuals. For example,

people are dra#ed into armies and regularly sent into ba$le, even though it is certain that some of them will

die. Is it ethical for a government to dra# people and send them into harm's way? Is this a case of trea!ng a

person as a means to an end?

We have seen that duty and rights-based ethics are "flip sides" of the same coin. One theory emphasizes

how people should behave toward each another; the other emphasizes that an individual should be

confident that her human rights will be acknowledged and respected. So the above example could be

rewri$en from the perspec!ve of the rights-based approach. A person has a right to be respected on her

own account rather than treated as a means to an end, yet we see that socie!es regularly sacrifice their

members. The universalism of rights-based ethics does not appear to allow for this societal choice.

35. How can I apply deontology in real life?

When confronted with an ethical dilemma, consider:

Which op!on is simply the right thing to do?

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What du!es or obliga!ons do you need to consider?

Which op!on best respects the rights of all stakeholders?

Which op!on treats people fairly and equally?

Which op!on has the best mo!va!on or inten!on?

If applicable: Which op!on is supported by a professional code of conduct?

36. What is virtue ethics?

Thinkers who embrace virtue ethics emphasize that the sort of person we choose to be cons!tutes the

heart of our ethical being. If you want to behave virtuously, become a virtuous person.

Certain traits—for instance, honesty, compassion, generosity, courage—seem to be universally admired.

These strengths of character are virtues. To acquire these virtues, follow the example of persons who

possess them. Once acquired, these virtues may be trusted to guide our decisions about how to act, even in

difficult situa!ons. A person might think of a religious figure, virtuous rela!ve, or even a favorite comic book

superhero, and use that person as a role model for how to behave.

37. What is care ethics?

Care ethics, or "ethics of care" places significance on rela!onships and humans' interdependency on each

other. It could be seen as related to virtue ethics because caring is a type of virtue, and is universal because

the impulse to care is present in all human socie!es.

In care ethics, the ethical actor considers what op!on would be, not just fair, but compassionate. Ethical

decisions may be made because of emo!onal connec!ons or a$achments to others. Given a dilemma, you

may choose one op!on because your loved one is involved, while another op!on may be more reasonable

to you when the people involved are strangers.

Care ethicists argue that all of us have been or will be in a posi!on of needing care, of being vulnerable, at

various points in our lives. As such, society works best when we take care of each other. Virtuous people

should want to help those who need help- not just to protect human rights, but because we care.

In The Hunger Games, the main character Katniss uses care ethics. When her younger sister, Prim, is

selected for the games and faces certain death, Katniss volunteers to take Prim's place, not because she

thinks the games are wrong (deontology), nor because she thinks she'll win (u!litarianism) but because she

loves Prim and will do anything to protect her. During the games, her feelings of care for Prim lead her to

also act to protect Rue, a fellow contestant who reminds her of Prim (Collins, 2008).

38. How does virtue ethics operate?

Virtue ethicists think that the main ques!on in ethical reasoning should be not" How should I now act?" but

"What kind of person do I want to be?" Developing virtues that we admire in others and avoiding ac!ons

that we recognize as vicious develops our moral sensi!vity: our awareness of how our ac!ons affect others.

Virtuous persons are able to empathize, to imagine themselves in another person's shoes, and to look at an

issue from other people's perspec!ves.

Virtuous individuals are also thought to be able to draw upon willpower not possessed by those who

compromise their moral principles in favor of fame, money, sex, or power.

39. What kinds of ques!ons are asked by virtue ethics?

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Virtue ethics focuses more on a person's approach to living than on par!cular choices and ac!ons and so

has less to say about specific courses of ac!on or public policies. Instead, this ethical approach posed

broader ques!ons such as these:

How should I live?

What is the good life?

Are ethical virtue and genuine happiness compa!ble?

What are proper family, civic, and cosmopolitan virtues?

Because of the broad nature of the ques!ons posed by virtue ethics, ethicists some!mes disagree as to

whether this theory actually offers an alterna!ve to the u!litarian and deontological approaches to ethical

reasoning. How does someone who follows virtue ethics determine what the virtues are without applying

some yards!ck such as those provided by u!litarian and deontological ethics?

U!litarianism and deontology are hard-universalist theories, each claiming that one ethical principle is

binding on all people regardless of !me or place. Virtue ethics does not make this claim. Those who favor

this theory may hold that certain virtues like compassion, honesty, and integrity transcend !me and culture.

But they do not aim to iden!fy universal principles that can be applied in all moral situa!ons. Instead they

accept that many things described as virtues and vices are cultural and that some of our primary ethical

obliga!ons are based on our emo!onal rela!onships and what we owe to people we care about. In the end,

though, virtue ethicists will always ask themselves, "What would a good person do?"

40. How has virtue ethics been applied in the real world?

Someone employing virtue ethics will consider what ac!on will most help her become a be$er person.

Virtue ethics arguments will discuss ideals as the mo!va!on for ac!ng. In December 2014, Senator John

McCain delivered a floor statement to the US Senate, condemning CIA interroga!on methods. He deplored

the use of torture by our country:

Torture's failure to serve its intended purpose isn't the main reason to oppose its use. I have o#en said, and

will always maintain, that this ques!on isn't about our enemies; it's about us. It's about who we were, who

we are and who we aspire to be. It's about how we represent ourselves to the world. (McCain, 2014)

41. What is the main weakness of virtue ethics?

Virtue ethics may seem to avoid some of the apparent flaws of duty-based ethics and of u!litarianism. A

person guided by virtue ethics would not be bound by strict rules or the duty to abide by a state's legal

code. Presumably, then, an individual who has cul!vated a compassionate personality consistent with virtue

ethics would not easily surrender a friend's hiding place in order to avoid having to tell a lie, as would seem

to be required by duty ethics. Nor would a person guided by virtue ethics be bound by the "tyranny of the

(happy) majority" that appears to be an aspect of u!litarianism.

On the other hand, some thinkers argue that virtue ethics provides vague and ambiguous advice. Because of

its emphasis on the imprecise and highly contextual nature of ethics, virtue ethics is o#en cri!cized as

insufficient as a guide to taking specific ac!on.

42. How can I apply virtue ethics in real life?

When confronted with an ethical dilemma, consider:

Which op!on would a good person choose?

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Would I feel comfortable if everyone knew I'd made that choice?

Which op!on shows care for those that are vulnerable?

What virtues and vices apply in this context?

What is the proper applica!on/ measure of virtues appropriate to this choice?

43. How do these theories fit into my ethics toolbox?

The ethical theories described in this sec!on are powerful tools that should be included in a cri!cal thinker's

"ethics toolbox." Perspec!ves rooted in ethical theories o#en play very direct roles in ethical analysis. In

addi!on, such perspec!ves can help you develop you own ethics-based arguments. Equip your ethics

toolbox with all of these tools: your ethical intui!ons and sense your conscience; your awareness of cultural

tradi!ons; and the insights you can gain from psychological studies and philosophical theories. These tools

allow people with even opposing perspec!ves on today's ethical issues to debate each other courteously

and skillfully.

44. How do I use ethical reasoning to make decisions?

Making good ethical decisions takes prac!ce. Our ins!nct or "gut" can draw us to selfish choices, so we

need to step back and think cri!cally about ethical dilemmas rather than just jumping to our first solu!on.

We need to consider all the elements involved:

Who is affected?

Who is making the decision?

What are the known facts and circumstances?

How ethical are the possible ac!ons?

The framework below can help guide you through this process. It is not a checklist of steps; rather, decision

making is an itera!ve process in which learning a new fact may cause you to revise earlier thoughts on the

situa!on.

45. How do I recognize an ethical situa!on?

Iden!fying an ethical situa!onwill require you to research the facts of a situa!on and to ask whether

stakeholders must consider ques!ons about the moral rightness or wrongness of public policy or personal

behavior. To help you iden!fy and describe the nature of the ethical issue, ask the following:

Does the situa!on require individuals to engage inethical judgments? Do you find yourself thinking

about whether an ac!on is morally right or wrong or whether a person's mo!ves are morally good or

bad? Could you debate what, morally, someone "should" or "ought to" do in the situa!on?

Does the situa!on seem to pose an ethical conflic'or one or more stakeholder? That is, does there

seem be a clash between what stakeholders "ought to do" and what they "want to do"?

Does the situa!on pose anethical dilemmafor one or more stakeholders? That is, does it seem as if

someone is pulled between compe!ng ethical demands, each calling for behavior that would be ethical

but with one ac!on making it impossible to perform the other, equally jus!fiable ac!on? Are there

values that are in conflict?

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You also should consider whether anyprofessional codesare relevant to the situa!on. O#en professional

codes spell out the ethical or moral obliga!ons of members of a profession. Compare any relevant

professional code with the behavior of par!cipants in that situa!on who may be bound by that code. Was

their behavior consistent with that code? Were there any compe!ngnormsor codes of behavior that put

par!cipants in the midst of an ethical dilemma?

In an ethical situa!on, a difficult decision or mul!ple difficult decisions will need to be made.

46. How do I iden!fy stakeholders?

Usually, any complex topic features mul!ple stakeholders: people who have an interest in or are affected by

the outcome of decisions revolving around the situa!on. These different par!es are not all affected in the

same way, and therefore, their perspec!ves on the topic will differ. Review how to iden!fy stakeholders in

Core 101—Academic Argument Essay (Core Curriculum, 2016).

47. How do I iden!fy the different perspec!ves and posi!ons held by stakeholders?

A stakeholder'sperspec!ve or posi!onis based upon the stakeholder's rela!onship to the situa!on. That

rela!onship can be captured by asking ques!ons about power, support, influence, and need in the context

of the situa!on that the stakeholder has an interest in.

Power—How much decision-making authority does the stakeholder have over the situa!on?

Support—How strongly is the stakeholder for or against the idea?

Influence—How much ability does the stakeholder have to affect the decisions made by other people?

Need—For the stakeholder to benefit, what does she need to have happen (or not happen) in the

situa!on?

Be sure to look for interests and perspec!ves that may be shared by different stakeholders, and be certain

that you do not automa!cally side with the stakeholders who have the most power and influence. If you

gravitate toward the par!es with the most power and influence, you may end up ignoring the individuals or

groups with the most need, the ones who may be badly hurt by an unethical decision.

48. How can I research stakeholder posi!ons?

When you research an issue, look beyond yes/no, pro/con arguments in order to see the people involved in

the situa!on. Remember that o#en there are more than the oversimplified "two sides," so be open to

iden!fying more than two stakeholders.

Make a list of the individuals and groups who affect or are affected by the issue. Add to the list as your

research uncovers addi!onal aspects of the situa!on that bring in addi!onal stakeholders.

Analyze the posi!ons held by each stakeholder, looking in-depth at their involvement.Go to the Appendix

for a list of possible ques!ons to research (Core Curriculum, "Appendix D—Core 202, 2016).

49. How do I iden!fy the ethical actor?

Within that set of stakeholders, iden!fy which is the one (or ones) in a posi!on to take ac!on. It could be an

individual, a group, or an ins!tu!on. Those are the ethical actors, who will exercise the decision related to

the ethical situa!on.

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The ethical actor may be you, but it's also probable in this class that you will research case studies of ethical

situa!ons in the wider world. In such assignments, focus your a$en!on on the people and en!!es that can

and need to take ac!on in order for this situa!on to be resolved. Avoid vic!m blaming—looking at

stakeholders and condemning them for ge(ng themselves into the current situa!on, or trying to rewrite

history so that the situa!on wouldn't exist. Concentrate on the facts of the case as they relate to the

decision making process.

50. How can I use cri!cal thinking in this process?

How can a person decide whether a certain act is ethical without being influenced by his biases? The

though'ul development of criteriais one method to keep biases from having an excessive influence on the

group's decision-making process. Criteria are carefully considered, objec!ve principles that can be applied to

a situa!on in order to reach measured conclusions.

51. What are criteria?

Criteriaare the standards you apply to develop and evalua!on whether a solu!on to a problem is "good" or

"right." People apply criteria to solve both ethical and nonethical problems.

Criteria need to be specific and measurable in some fashion to allow them to be used to judge whether a

solu!on is likely to successfully address a problem. See the Appendix for more informa!on on criteria (Core

Curriculum, "Appendix D—Core 202, 2016).

52. How do I iden!fy possible ac!ons?

When you have iden!fied who can act and what criteria is essen!al, you can now brainstorm op!ons for

ac!ons. You can use the major ethical perspec!ves to help you:

What ac!on would result in the best results?

What ac!on would respect stakeholders' rights?

What ac!on would respect the ethical actor's obliga!ons?

What ac!on would lead the ethical actor to being a virtuous person or organiza!on?

What ac!on gives extra considera!on to those who are vulnerable?

If this is a professional situa!on, you should also check to see if there are any codes of conduct to consult.

If you think of other ac!ons, apply the different ethical perspec!ves to them to see if they are ethical.

53. How do I evaluate the possible op!ons?

Some!mes all the theories point to the same ac!on, but usually there are differences. At this point, you

need to consider the specific situa!on and the context of the ethical actor. Which perspec!ve is most

appropriate given these circumstances?

For example, there is a limited amount of medica!on available for a very infec!ous disease. How do you

decide who receives the medica!on?

If the ethical actor is a government official deciding on a policy, one would probably turn to u!litarianism:

what would be the best result for the most number of people?

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If the ethical actor is a physician, she may turn to deontology: what are her professional obliga!ons?

If the ethical actor is the mother of a sick child, she may give up her dose to save the baby.

54. How can mapping or diagramming help me to examine the consequences of decisions or posi!ons with

ethical consequences?

Like many ethical issues, the one you are examining may be very complex, with factors that include

mul!ple stakeholders

mul!ple ethical actors

mul!ple ethical perspec!ves, and

mul!ple ac!ons

Because of the number of stakeholders, actors, perspec!ves, and agents, you may be considering a large

number of op!ons. You will have to

formulate a full list of possible ac!ons, taking into account both all the stake holders and all the ethical

perspec!ves;

examine each op!on to determine the benefits to various stakeholders;

examine each op!on to determine the burdens and risks to various stakeholders; and

evaluate the prac!cality, legality, and appropriateness of each ac!on.

With so many factors and op!ons to consider, you may benefit from mapping or diagramming the various

op!ons to keep track of the rela!onships between stakeholders, agents, and perspec!ves, and each ac!on

and its impact.

55. What else should I consider before ac!ng?

You should do a cri!cal thinking check to make sure you are not falling into any fallacious thinking or

ra!onaliza!ons to jus!fy an op!on that is selfish or otherwise unethical. Would you be okay with your

decision being widely known and associated with you?

56. Am I done a#er ac!ng?

No. It's essen!al to examine how the decision turned out and consider what lessons you may have learned

from it.

57. Do people really do all this when making ethical decisions?

In an ideal world, yes! You may recall from previous experience that cri!cal thinking is a learned skill. Ethical

decision making builds on that pla'orm. At first, it probably seems clunky and ar!ficial, but with prac!ce

you begin to internalize the analysis. Over !me, you move away from ins!nctual, gut-level thinking to a

using a more cri!cal lens. We can, unfortunately, find plenty examples of ethical decision making gone bad

(aka ethical viola!ons). In 2001, GM discovered there was a defect in its Saturn Ion's igni!on switch, but

released the new car model without fixing it. Over the next 12 years, GM engineers alerted the company

that many of the models had the same defect, but GM execu!ves decided it would be too expensive to fix

the problem. It wasn't un!l 2014 that GM admi$ed that the faulty switch was the cause of 31 crashes and

at least 13 deaths, and recalled over 1 million vehicles. An inves!ga!on revealed that GM "made a business

decision not to fix this problem" (Basu, 2014).

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For a posi!ve example of ethical decision making, listen to or read the transcript of the On The

Media interview with a newspaper editor who published the names of high schoolers who were using

Twi$er to bully classmates. See if you can iden!fy the different aspects of ethical decision making from the

editor (Garfield & DeRienzo, 2013).

References

Anand, V., Ashforth, B. E., & Joshi, M. (2004). Business as usual: The acceptance and perpetua!on of

corrup!on in organiza!ons. Academy of Management Execu!ve, 18(2).

h$p://actoolkit.unprme.org/wp-content/resourcepdf/anand_et_al._ame_2004.pdf

Basu, T. (2014, March 31). Timeline: A history of GM's igni!on switch defect. In NPR, Business. WAMU.

h$p://www.npr.org/2014/03/31/297158876/!meline-a-history-of-gms-igni!on-switch-defect

Collins, S. (2008). The hunger games. Scholas!c. h$ps://books.google.com/books?isbn=0439023521

Core Curriculum. (2016). Appendix D—Core 202. Radford University core handbook.

h$ps://lcubbison.pressbooks.com/back-ma$er/appendix-d-core-202/

Core Curriculum. (2016). Core 101—Academic Argument Essay. Radford University core handbook.

h$ps://lcubbison.pressbooks.com/chapter/core-101-academic-argument-essay/#101_AA_obj_3_3

Core Curriculum. (2016). Core 201—The Logical Structure of Arguments. Radford University core handbook.

h$ps://lcubbison.pressbooks.com/chapter/core-201-logical-structure-arguments/#201aaf

Fieser, J. (n.d.). Ethics. Internet Encyclopedia of Philosophy. h$p://www.iep.utm.edu/ethics/

Garfield, B., and DeRienzo, M. (2013, March 22). The iden!ty of minors. In WNYC Studios, On The Media.

WNYC. h$p://www.wnyc.org/story/277595-iden!ty-minors/

Hugo, V. (1887). Les misérables. (I. F. Hapgood, Trans.). Thomas Y. Crowell & Co. (Original work published

1862) h$p://www.gutenberg.org/files/135/135-h/135-h.htm

James, W. (2000). In G. B. Gunn (Ed.), Pragma!sm and other wri!ngs (pp. 244–245). Penguin.

h$ps://books.google.com/books?isbn=0140437355

Jefferson, T. (1776). Declara!on of independence.

h$p://www.archives.gov/exhibits/charters/declara!on_transcript.html

Le Guin, U. (1973). The ones who walk away from Omelas. h$p://engl210-

deykute.wikispaces.umb.edu/file/view/omelas.pdf

Livingston, B. (2011, May 30). Jim Tressel resigns at Ohio State having paid the price for his sins of

omission. Cleveland.com.

h$p://www.cleveland.com/livingston/index.ssf/2011/05/jim_tressel_leaves_ohio_state.html

McCain, J. (2014, December 9). Floor statement by Senator John McCain on Senate Intelligence Commi$ee

report on CIA interroga!on methods. John McCain, U.S. Senator–Arizona website.

h$p://www.mccain.senate.gov/public/index.cfm/2014/12/floor-statement-by-sen-mccain-on-

senate-intelligence-commi$ee-report-on-cia-interroga!on-methods

Sartre, J. (1946). Existen!alism is a humanism. [Lecture].

h$ps://www.marxists.org/reference/archive/sartre/works/exist/sartre.htm

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United Na!ons. (1948). The universal declara!on of human rights. h$p://www.un.org/en/universal-

declara!on-human-rights/index.html

Licenses and A$ribu!ons

Core 202 - Ethical Reasoning and Analysis (h$ps://lcubbison.pressbooks.com/chapter/core-202-ethical-

reasoning/) from Radford University Core Handbook comprises public domain material in the United

States. UMGC has modified this work.

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external sites.

6/8/21, 9:41 PMProblem Analysis

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Problem Analysis

Problem analysis involves framing the issue by defining its boundaries, establishing criteria with which to

select from alterna!ves, and developing conclusions based on available informa!on. Analyzing a problem

may not result in a decision, although the results are an important ingredient in all decision making.

Another way to consider problem analysis is a process that includes iden!fying and defining the problem,

gathering informa!on about the problem, and deciding if one or a group will begin work to solve the

problem. A decision to solve the problem leads to analysis of the problem, in this model, asking the what,

why, how, and other basic ques!ons. From this point, the group can re-visit the decision to solve and refine

any issues (risk, cost, feasibility, for example.)

References

Defining decision making. (n.d.). Boundless Management. Retrieved from

h"ps://www.boundless.com/management/textbooks/boundless-management-textbook/decision-

making-10/decision-making-in-management-75/defining-decision-making-366-3930/

Nagy, J. (n.d.). Defining and analyzing the problem. Community Toolbox. Retrieved from

h"p://ctb.ku.edu/en/table-of-contents/analyze/analyze-community-problems-and-solu!ons/define-

analyze-problem/main

Problem Analysis: Defining Decision Making

(/content/umuc/tgs/pro/pro600/2212/learning-resource-list/problem-analysis--

defining-decision-making.html?ou=584686)

Problem Analysis: System Analysis (/content/dam/course-content/tgs/dcl/dcl-

600/document/SystemsAnalysis_checked.pdf?ou=584686)

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Learning Topic

Resources

6/8/21, 9:20 PMTrouble in the Truss Construction Shop

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Trouble in the Truss Construc!on Shop

Two weeks ago, during a quality assurance load test, the truss being tested fragmented along its horizontal

axis and splintered, causing a large piece of the truss to break apart and fall on a crane operator who was

helping to conduct the test. The crane operator sustained head injuries and is in cri!cal but stable condi!on

at a local hospital. This accident sent shock waves through the Truss Construc!on Enterprise division

because the company has heavily invested in a new engineering and manufacturing process to produce a

cost-effec!ve truss for new homes. This process and its trusses have been touted to be on the cu#ng edge

of construc!on technology, especially for low-cost housing in overseas markets.

The company safety officer, QA manager, and engineer have signed statements that the test being

conducted pushed the load tes!ng slightly beyond the high threshold of acceptable load bearing, though the

extra load was not expected to cause the truss to fail. In fact, the trusses were adver!sed to meet "high

commercial load" requirements.

Employees in the engineering shop have been asking if the manufacturing or engineering process is flawed

and if the trusses that they are building could fail at even lower loads. Company memos have focused on

produc!on and on con!nuing the tes!ng at lower thresholds. Produc!on managers are direc!ng employees

to con!nue the current produc!on schedule to meet orders for the trusses.

The sales department is keeping an eye on the situa!on. They are concerned that if there is any delay in

shipping, customers will pull their orders, which would be disastrous for revenues.

Obinna Faruch, a produc!on line worker, leaked the details of the accident and test thresholds to the press.

Two weeks later, she was terminated for documented poor performance, according to managers.

The company public rela!ons department has issued a general statement that the company has taken all

ac!on to ensure that this type of workplace accident would not happen again. They are planning a campaign

to communicate the facts of the accident and what the company is doing to ensure a safe working

environment.

Sales is asking PR to monitor social media for nega!ve comments and to prepare a similar statement about

the quality and safety of the truss product line in case it is needed.

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Course Resource

6/10/21, 6:47 AMCritical Thinking and Analysis

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Cri!cal Thinking and Analysis

First, let’s consider what it means to engage in cri!cal thinking. While the applica!on of cri!cal thinking may

vary across disciplines, the steps are universal. Adapted from the wri!ngs of Bassham, Irwin, Nardone, and

Wallace (2011), Lau (2011), and Lau and Chan (2015), cri!cal thinking involves thinking clearly and

systema!cally, and includes:

formula!ng ideas succinctly and precisely

iden!fying the relevance and importance of ideas

understanding the logical connec!ons between ideas

iden!fying, construc!ng, and evalua!ng arguments, claims, and evidence

recognizing explicit and implicit assump!ons, arguments, and biases

detec!ng inconsistencies and common mistakes in reasoning

formula!ng clear defensible ideas and conclusions

evalua!ng the pros and cons of decisions

reflec!ng on one’s own beliefs and values

applying ethical decision making

References

Bassham, G., Irwin, W., Nardone, H., & Wallace, J. (2011). Cri!cal thinking: A student's introduc!on. (4th ed.)

New York, NY: The McGraw Hill Companies.

Lau, J. (2011). An introduc!on to cri!cal thinking and crea!vity: Think more, think be"er. Hoboken, NJ:

John Wiley & Sons, Inc.

Lau, J., & Chan, J. (2015). What is cri!cal thinking? Retrieved

from h"p://philosophy.hku.hk/think/cri!cal/ct.ph

Resources

Cri!cal Thinking: What It Is and Why It Counts (/content/dam/course-content/tgs/pro/pro-

600/document/Cri!calThinking_WhatItIsandWhyItCounts_checked.pdf?ou=584686)

Moving Beyond Biases and Stereotypes: The Cri!cal Stance (/content/dam/course-

content/tgs/pro/pro-600/document/movingBeyondOLR_checked.pdf?ou=584686)

Learning Topic

6/10/21, 6:47 AMCritical Thinking and Analysis

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© 2021 University of Maryland Global Campus

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external sites.