By Michael Laris
Washington Post Staff Writer
Sunday, December 14, 2008
Faced with painful choices about who will suffer most from looming budget cuts, Alexandria officials have taken the unusual step of paying a professional ethicist to help them grapple with the moral issues involved.
Just a few of the vexing decisions his advice helped Alexandria policymakers confront in recent weeks: They took apartments being built for the mentally ill and temporarily turned them into housing for the disabled. They cut a parenting counselor for jailed minors with kids but preserved aid for belligerent preschoolers. They scaled back drug prevention but kept the methadone pills available to ease the cravings of withdrawal.
"It is very uncomfortable to admit you're going to have to say no. It's very uncomfortable to make decisions that, quite frankly, are going to make some people's lives go worse," said Michael A. Gillette, an ethicist who helped mental health officials in Alexandria write guidelines for prioritizing assistance when there's not enough money to go around. At the urging of top city officials, Gillette also pushed more than 100 other senior and mid-level managers to wrestle with the ethics of shrinking government.
"If the limb comes off, at least you saved the life. That's what true scarcity feels like," said Gillette, a Lynchburg, Va., City Council member who often uses the battlefield clarity of old "M*A*S*H" episodes to goad his listeners.
With resources scarce across the region, talk about spending increases and "best practices" has given way to the deflating and unfamiliar concept of "triage." Montgomery County teachers agreed not to take 5 percent raises to keep class sizes stable. Nonessential Fairfax County workers will miss work Jan. 2 so they can spare more jobs from layoffs.
In Alexandria, social service officials first began seeking Gillette's advice on clinical quandaries, which represent the bulk of his work. But over time, especially since the weakening real estate market stung the city last year, money questions have gained urgency. They now pay him a $9,000 annual consulting fee.
Although it's common for public hospitals to hire ethicists to help make difficult patient-care decisions, it is unusual for local officials to seek their advice on budget matters.
"I haven't heard of any particular attempt to get consultation on that," said David A. Treasure, director of Maryland's Office of Budget Analysis. That doesn't mean ethics don't underlie many public actions, he said. "Informally, it's just part of the ethos of working in this domain. You can't escape it," he said.
But with money tight and worthy hands all around, from police and teachers to social workers and parks, the explicit guidance on ethics has been valuable, said Alexandria City Manager James K. Hartmann.
It's vital "that everybody have some grounding and some empathy for those that may be hurt," Hartmann said. "It causes us to have more discussion and debate and understanding for the consequences of our actions."
Not everyone embraces the idea of paying for ethical advice.
"Every penny is essential," said Pat Troy, a former Republican City Council candidate who owns an Old Town restaurant. If city officials "aren't smart enough to be able to figure these things out for themselves, something's wrong."
But officials counter that the decisions they face are hardly cut and dried. Staff members in Alexandria sought last-minute advice from Gillette this month as they struggled with a decision that pitted core values against each other.
At issue was a proposal to temporarily move residents with mental disabilities into 12 new beds that were originally being prepared for mentally ill homeless people. The facility, called Safe Haven, was meant for people who might be disqualified from typical shelters because of bad behavior, including fighting.
"Some people just can't abide by those rules because of their illness or because of substance abuse problems," said Michael Gilmore, executive director of Alexandria's Community Services Board, which covers mental health, addiction and intellectual disabilities.
"They are told not to come back," Gilmore said. "That's why we created the program."
But the board also serves mentally disabled residents, including some who live in a home that is not completely accessible to the disabled. Given that officials had to find more than $2.3 million in cuts, a choice needed to be made between the two groups.
The services board, with Gillette's help, developed a checklist for who has priority within programs.
Services required by law rank first. Money then goes to those enrolled. If there's more, it goes to people with no other alternatives. Then to those with "serious and imminent" needs. Efficiency and effectiveness come next, then a ranking by level of need. Finally, if everyone there is covered, it's first come first served.
But it's even tougher to decide between deserving programs, where the checklist is used as a reference.
In this case, the homeless "in fact are most in need of services," Gilmore said. But they had made a promise to house the mentally disabled residents they have.
They decided to make the homeless wait.
It's the difficulty of such decisions that prompted Alexandria to expand Gillette's reach.
"What we learned from him was a form of tough love," said Bruce Johnson, director of Alexandria's office of management and budget. Johnson argues against the bureaucratic instinct for equal cuts.
"If you were a village elder of an African village, and somehow or other you were running out of food, and you looked around, would you cut everybody's food allocation by 3 percent, or 2 percent, equally?" Johnson asked. "No." The young, the old and the healthy would be treated differently.
With references to Milton Friedman and Immanuel Kant, red and blue graphs on fairness and case studies, Gillette has talked local officials through "The Justification of Rationing." He argued that it is moral to cut some people out of a public resource only if there's a true shortage. One fair approach would "maximize benefit to the least advantaged," he said.
Or, as Gillette said, a key question is: "If you don't serve them, will they crash and burn?"
That's why drug treatment took precedence over prevention in recent discussions.
One striking aspect of the services board's ethical guidelines is the emphasis on those being served. They have priority "even if new potential customers present with equal or greater need."
"There's always going to be someone sicker than you," Gillette said. "It doesn't make sense to remove people from a 12-week program on the fourth week."
For some who have benefited from the government's choices, such as Winston Burse, who lived homeless and on heroin before getting psychiatric care and housing in Alexandria, the idea of rationing is unthinkable.
"I think everybody needs help. How would you limit that? I wouldn't do it," he said.
The social service cuts aren't final. After Alexandria's staff members set a budget, the City Council will make the call.
"There are just raw political considerations. There are objective considerations about what works and what doesn't, and what gives you the most bang for the buck. And there are ethical considerations," said council member Rob Krupicka (D).
"We're cutting popular programs that work. We're raising taxes. And we're cutting jobs," he said. "Politicians wouldn't go there in an election year . . . unless they had to."