For this assignment, you will appraise a clinical practice guideline on a topic chosen by your faculty member.

Ground yourself in the topic (again).
Read/ Review the clinical practice guideline provided to you by your course faculty.

The article you will appraise is available as a PDF in the Course Readings. The reference is here:
US Preventive Services Task Force, Owens, D. K., Davidson, K. W., Krist, A. H., Barry, M. J., Cabana, M., Caughey, A. B., Curry, S. J., Donahue, K., Doubeni, C. A., Epling, J. W., Kubik, M., Ogedegbe, G., Pbert, L., Silverstein, M., Simon, M. A., Tseng, C.-W., & Wong, J. B. (2020). Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents: US Preventive Services Task Force Recommendation Statement. JAMA, 323(16), 1590. https://doi.org/10.1001/jama.2020.4679

Criteria
(1) This criterion is linked to a Learning OutcomePICO Question
The PICO question at the top of the worksheet is complete and reflective of the Faculty-provided PICO question.
(2) Validity
The 5 questions related to guideline validity are answered clearly and succinctly with evidence from the guideline. The student demonstrates graduate-level critical thinking in responses. Guideline page numbers are included where applicable.
(3) This criterion is linked to a Learning OutcomeResults
The 3 questions related to the guideline results are answered clearly and succinctly with evidence from the guideline itself. The student demonstrates graduate-level critical thinking in responses. Guideline page numbers are included where applicable.
(4) Results Application
The 3 questions related to the application of the results “Will the results help me in caring for my patient?” are answered clearly and succinctly with evidence from the guideline itself. The student demonstrates graduate-level critical thinking in responses. Guideline page numbers are included where applicable.
(5) This criterion is linked to a Learning OutcomeSpelling/ Grammar/ APA
The student demonstrates graduate level spelling, grammar, and APA formatting of citations within the answers. Page numbers ought to be included when direct quotes are provided. The CPG reference at the top of worksheet is in correct APA format.
(6) Overall Appraisal
Overall Appraisal: In one succinct paragraph, give a narrative overall appraisal that includes a summary of the strengths and weaknesses of the guideline, as well as its use for the identified PICO question. Use APA format for citations and scholarly graduate level writing.

Guide to the Critical Appraisal of
Clinical Practice Guidelines (CPG)

Student Name:
Faculty name:

Reference of CPG:

1. WHAT QUESTION ARE YOU TRYING TO ANSWER?

Patients

Intervention

Comparison

Outcome(s)

2. ARE THE RESULTS OF THE GUIDELINES VALID?

Questions that need asking

What is this, and where do I find this information?

Details from Assigned CPG
Include page number as applicable

Is the group, committee, or organization
that developed the guidelines clearly identified?

Yes / No

Cant tell

This information is usually located either right at the front of the guidelines, or in the back of the document in an appendix. For some guideline groups, this information is located on their website at point of download of the guideline itself.

Did authors declare
conflicts of interest among all parties involved in guideline preparation and consensus?

Yes / No
Cant tell

Conflict of interest is essential to locate within a clinical practice guideline (CPG) to ensure validity. Sometimes the writers of CPGs have financial or expert relationships with pharmaceutical companies or are extensively involved in other research studies that might negatively bias the development of objective CPGs. Conflict of interest should ideally be stated up front within the guideline, but may also be included in a paragraph at the very back of a document.

Is there
proof of a systematic literature search and strategic selection of articles for review?
(
Was it a SYSTEMATIC PROCESS?)

Yes / No
Cant tell

All CPGs need to describe the literature review (and the timeline; example 2000-2009) whereby evidence was located. Specific databases where the search occurred should be cited (e.g., Medline, PubMed, Embase, Cochrane). Again, this should be noted within the first few pages of the CPG.

Have
evidence ratings or indicators of value been indicated for each guideline?

Yes / No
Cant tell

CPGs should be developed by consensus. In doing so, there should be a specific scale to rate the quality and strength of evidence and also the consensus result. This might look like Grade 1a, which might suggest a highly rated recommendation and a highly rated consensus among the CPG committee. This should be noted

for each and every guideline
within the CPG and be noted throughout the document.

To what extent has
expert opinion been identified for particular guidelines is it extensive?

Yes / No
Cant tell

Sometimes, background research is just not available to help inform CPGs on particular topics. In these instances, guideline groups or committees sometimes choose to create a statement or guideline that is based solely on expert opinion or experience of experts. While a few statements of this nature are usually accepted within guidelines, a high percentage of statements within a CPG may be inappropriate. Further, clinicians using these guidelines must consider the risks and value of using expert opinion-based guidelines to make clinical decisions.

3. WHAT ARE THE RESULTS?

Questions that need asking

What is this, and where do I find this information?

Details from Assigned CPG
Include page number as applicable

Is there a clear message on the
clinical importance and practical value for use of these guidelines?

Yes / No
Cant tell

All CPGs must be written in practical and implementable statements. They must not be vague or generic; they are intended to be actionable and easy to understand without risk of misinterpretation.

Is there discussion
of benefits, harm, risks, and cost impacts?

Yes / No
Cant tell

High-quality CPGs provide specific information within the guidelines about patient-specific benefits, harms/risks, and also cost of implementation of the guidelines in clinical settings. This is essential to note because it informs the prospective user of the CPG of what implementation aspects might warrant further review.

Are these guidelines of
recent age? Do the results
include reference to currently available treatments or interventions?

Yes / No
Cant tell

Most clinical practices note changes every 5 years or so. As such, a CPG that is older than this timeframe may not be appropriate, particularly if there is mention of older and less-used medications particular to your clinical practice setting.

4. WILL THE RESULTS HELP ME IN CARING FOR MY PATIENT?

Questions that need asking

Response

What is this?

Details from Assigned CPG
Include page number as applicable

Are the guidelines presented in a
user-friendly and easy-to-follow format?

Yes / No
Cant tell

Guidelines that are difficult to understand or hard to follow can be prone to misinterpretation. There is also greater likelihood that the CPG will not be embraced and used consistently in clinical settings if it is hard to interpret.

Do the guidelines offer
next steps for practical implementation; recognition of implementation barriers?

Yes / No
Cant tell

Most good CPGs include suggestions for next steps including a standardized documentation, standing-orders form, or audit assessment sheet, for example. This may also include a sample patient or family education pamphlet, posters for health care professionals, electronic flags for charts, or other resources. It is a good sign that some suggestions and tools are provided for implementation by guideline developers.

Is there discussion of
clinical flexibility for application in multiple or diverse clinical settings?

Yes / No
Cant tell

Remember that CPGs created exclusively for implementation in large tertiary facilities may not be directly applicable in smaller or community-based health care settings. A strong CPG should identify some general recommendations of special implementation for different settings. As an example, a CPG intended for use in hospitals may not necessarily be effective for implementation in rural clinic settings.

Overall Appraisal: In one succinct paragraph, give a narrative overall appraisal that includes a summary of the strengths and weaknesses of the guideline, as well as its use for the identified PICO question.

Guide to the Critical Appraisal of Clinical Practice Guidelines Page 1 of 2
Guide to the Critical Appraisal of Clinical Practice Guidelines Page 3 of 3

image1.png Primary Care Interventions for Prevention and Cessation of Tobacco Use
in Children and Adolescents
US Preventive Services Task Force Recommendation Statement
US Preventive Services Task Force

Summary of Recommendations

The USPSTF recommends that primary care clinicians provide interventions, including education or
brief counseling, to prevent initiation of tobacco use among school-aged children and adolescents. B

The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and
harms of primary carefeasible interventions for the cessation of tobacco use among school-aged
children and adolescents.

I

See the Figure for a more detailed summary of the recommendation for clinicians. See the Practice Considerations section for more information on effective
interventions to prevent initiation of tobacco use and for suggestions for practice regarding the I statement. USPSTF indicates US Preventive Services Task Force.

IMPORTANCE Tobacco use is the leading cause of preventable death in the US. An estimated
annual 480 000 deaths are attributable to tobacco use in adults, including from secondhand
smoke. It is estimated that every day about 1600 youth aged 12 to 17 years smoke their first
cigarette and that about 5.6 million adolescents alive today will die prematurely from a
smoking-related illness. Although conventional cigarette use has gradually declined among
children in the US since the late 1990s, tobacco use via electronic cigarettes (e-cigarettes) is
quickly rising and is now more common among youth than cigarette smoking. e-Cigarette
products usually contain nicotine, which is addictive, raising concerns about e-cigarette use
and nicotine addiction in children. Exposure to nicotine during adolescence can harm the
developing brain, which may affect brain function and cognition, attention, and mood; thus,
minimizing nicotine exposure from any tobacco product in youth is important.

OBJECTIVE To update its 2013 recommendation, the USPSTF commissioned a review of the
evidence on the benefits and harms of primary care interventions for tobacco use prevention
and cessation in children and adolescents. The current systematic review newly included
e-cigarettes as a tobacco product.

POPULATION This recommendation applies to school-aged children and adolescents younger
than 18 years.

EVIDENCE ASSESSMENT The USPSTF concludes with moderate certainty that primary
carefeasible behavioral interventions, including education or brief counseling, to prevent
tobacco use in school-aged children and adolescents have a moderate net benefit. The
USPSTF concludes that there is insufficient evidence to determine the balance of benefits
and harms of primary care interventions for tobacco cessation among school-aged children
and adolescents who already smoke, because of a lack of adequately powered studies on
behavioral counseling interventions and a lack of studies on medications.

RECOMMENDATION The USPSTF recommends that primary care clinicians provide
interventions, including education or brief counseling, to prevent initiation of tobacco use
among school-aged children and adolescents. (B recommendation) The USPSTF concludes
that the current evidence is insufficient to assess the balance of benefits and harms of
primary carefeasible interventions for the cessation of tobacco use among school-aged
children and adolescents. (I statement)

JAMA. 2020;323(16):1590-1598. doi:10.1001/jama.2020.4679

Editorial page 1563

Related article page 1599 and
JAMA Patient Page page 1626

Audio and Supplemental
content

CME Quiz at
jamacmelookup.com

Group Information: The US
Preventive Services Task Force
(USPSTF) members are listed at the
end of this article.

Corresponding Author: Douglas K.
Owens, MD, MS, Stanford University,
615 Crothers Way, Encina Commons,
Mail Code 6019, Stanford, CA
94305-6006 ([emailprotected]).

Clinical Review & Education

JAMA | US Preventive Services Task Force | RECOMMENDATION STATEMENT

1590 JAMA April 28, 2020 Volume 323, Number 16 (Reprinted) jama.com

2020 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 10/28/2022

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.4679?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2019.22312?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.3332?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.5349?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.4679?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.4679/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2020.4679/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

https://jama.jamanetwork.com/learning/article-quiz/10.1001/jama.2020.4679/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

mailto:[emailprotected]

http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

T obacco use is the leading cause of preventable death in
the US.1 An estimated annual 480 000 deaths are attrib-
utable to tobacco use in adults, including secondhand

smoke.1 It is estimated that every day about 1600 youth aged 12 to
17 years smoke their first cigarette2 and that about 5.6 million ado-
lescents alive today will die prematurely of a smoking-related
illness.1,3 Although conventional cigarette use has gradually
declined among children in the US since the late 1990s,4 tobacco
use via electronic cigarettes (e-cigarettes) is quickly rising and is
now more common among youth than cigarette smoking.
e-Cigarette sales in the US market have risen rapidly since 2007,5

and e-cigarette use by youth has been tracked in the National
Youth Tobacco Survey since 2011.1 From 2011 to 2019, current
e-cigarette use increased from 1.5% to 27.5% among high school
students6,7 (from an estimated 220 000 to 4.11 million students);
in 2019, 5.8% of high school students (an estimated 860 000 stu-
dents) used conventional cigarettes.7

e-Cigarette products usually contain nicotine,8 which is addic-
tive, raising concerns about e-cigarette use and nicotine addiction
in children.5 Evidence suggests an association between e-cigarette
use in nonsmoking adolescents and subsequent cigarette smoking
in young adults. Ever use of e-cigarettes is associated with
increased risk of ever use of combustible tobacco products.9 In
addition, as the degree of e-cigarette use increases, frequency and
intensity of smoking cigarettes also increases.9 Exposure to nico-
tine during adolescence can harm the developing brain, which may
affect brain function and cognition, attention, and mood1,5,10,11;
thus, minimizing nicotine exposure from any tobacco product in
youth is important. In 2019, an outbreak of e-cigarette, or vaping,
product useassociated lung injury (EVALI) occurred in the US;
approximately 15% of patients hospitalized with EVALI were
younger than 18 years.12 Vitamin E acetate, an additive to some
tetrahydrocannabinol-containing e-cigarettes, was found to be
strongly linked to the outbreak.12 Other tobacco products high
school students report using include cigars, cigarillos, and little
cigars (7.6%); smokeless tobacco (4.8%); hookahs (3.4%); and pipe
tobacco (1.1%).7 In 2019, cigar use (including cigarillos and little
cigars) surpassed cigarette use in high school students.7 See the
Definitions section for more information on tobacco products and
terminology used in this US Preventive Services Task Force
(USPSTF) recommendation.

USPSTF Assessment of Magnitude of Net Benefit
Available evidence on interventions to prevent and help youth quit
tobacco use almost exclusively focus on cigarette smoking. For this
recommendation, the US Preventive Services Task Force (USPSTF)
found this evidence to be most applicable to smoking combustible
products (including cigarettes, cigars, cigarillos, and little cigars) and
use of e-cigarettes (vaping).

See the Figure and Table 1 for more information on the USPSTF
recommendation rationale and assessment. For more details on the
methods the USPSTF uses to determine the net benefit, see the
USPSTF Procedure Manual.13 For a summary of the evidence that
served as the basis for the recommendations, see the review of the
evidence on the benefits and harms of primary care interventions for
tobacco use prevention and cessation in children and adolescents.14,15

Prevention
The USPSTF concludes with moderate certainty that primary care
feasible behavioral interventions, including education or brief coun-
seling, to prevent tobacco use in school-aged children and adoles-
cents have a moderate net benefit. The USPSTF found adequate
evidence that behavioral counseling interventions, such as face-to-
face or telephone interaction with a health care clinician, print ma-
terials, and computer applications, can have a moderate effect in pre-
venting initiation of tobacco use in school-aged children and
adolescents. The USPSTF sought but found no evidence on the
harms of behavioral counseling interventions for the prevention or
cessation of tobacco use; however, the USPSTF bounds the magni-
tude of potential harms of behavioral counseling interventions as
no greater than small, based on the absence of reported harms in
the literature and the noninvasive nature of the interventions
(Table 1).

Cessation
The USPSTF concludes that there is insufficient evidence to de-
termine the balance of benefits and harms of primary care interven-
tions for tobacco cessation among school-aged children and ado-
lescents who already smoke, because of a lack of adequately
powered studies on behavioral counseling interventions and a lack
of studies on medications.

The USPSTF found inadequate evidence on the benefit of be-
havioral counseling interventions for tobacco cessation in school-
aged children and adolescents because many studies had small
sample sizes and may not have been adequately powered to de-
tect a benefit, making it unclear whether the observed lack of ef-
fect of interventions was the result of intervention failure or lack of
statistical power. Although the USPSTF found no evidence on the
harms of behavioral counseling interventions, it bounds the mag-
nitude of potential harms of behavioral counseling interventions as
no greater than small, based on the absence of reported harms in
the literature and the noninvasive nature of the interventions.

The USPSTF found inadequate evidence on the benefits and
harms of medications for tobacco cessation in children and adoles-
cents, primarily because of an inadequate number of studies that
have evaluated tobacco cessation medications in this population.
Potential harms depend on the specific medication (Table 1).

Practice Considerations
Patient Population Under Consideration
This recommendation applies to school-aged children and adoles-
cents younger than 18 years. The USPSTF has issued a separate rec-
ommendation statement on interventions for tobacco use cessa-
tion in adults 18 years and older, including pregnant persons.16

Definitions
Tobacco use refers to use of any tobacco product. As defined by
the US Food and Drug Administration (FDA), tobacco products in-
clude any product made or derived from tobacco intended for hu-
man consumption (except products that meet the definition of
drugs), including, but not limited to, cigarettes, cigars (including ciga-
rillos and little cigars), dissolvable tobacco, hookah tobacco, nico-
tine gels, pipe tobacco, roll-your-own tobacco, smokeless tobacco

USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents US Preventive Services Task Force Clinical Review & Education

jama.com (Reprinted) JAMA April 28, 2020 Volume 323, Number 16 1591

2020 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 10/28/2022

http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

products (including dip, snuff, snus, and chewing tobacco), vapes,
e-cigarettes, hookah pens, and other electronic nicotine delivery sys-
tems. Smoking generally refers to the inhaling and exhaling of

smoke produced by combustible tobacco products such as ciga-
rettes, cigars, and pipes. Vaping refers to the inhaling and exhal-
ing of aerosols produced by e-cigarettes.17 Vape products usually

Table 1. Summary of USPSTF Rationalea

Rationale Prevention Cessation
Benefits of
intervention

Adequate evidence that behavioral counseling interventions
can have a moderate effect in preventing initiation of tobacco
use in school-aged children and adolescents

Inadequate evidence on behavioral counseling interventions for cessation
of tobacco use in school-aged children and adolescents because many
studies had small sample sizes and may not have been adequately
powered to detect a benefit

Inadequate evidence on medications for cessation of tobacco use in
school-aged children and adolescents because of an inadequate number
of studies

Harms of
intervention

Adequate evidence to bound harms of behavioral counseling
interventions as no greater than small based on the absence of
reported harms in the evidence, the noninvasive nature of the
interventions, and the low likelihood of serious harms

Adequate evidence to bound harms of behavioral counseling interventions
as no greater than small, based on the absence of reported harms in the
evidence, the noninvasive nature of the interventions, and the low
likelihood of serious harms

Inadequate evidence on harms of medications
USPSTF
assessment

Moderate certainty that primary carerelevant behavioral
interventions to prevent tobacco use in school-aged children
and adolescents have a moderate net benefit

Insufficient evidence to determine the balance of benefits and harms
of primary care interventions for tobacco cessation in school-aged
children and adolescents who already smoke

Abbreviation: USPSTF, US Preventive Services Task Force.
a See the eFigure in the Supplement for explanation of USPSTF grades and levels of evidence.

Figure. Clinician Summary: Primary Care Interventions for Prevention and Cessation of Tobacco Use in Children and Adolescents

What does the USPSTF
recommend?

School-aged children and adolescents who have not started to use tobacco: Grade B

To whom does this
recommendation apply?

Whats new?

How to implement this
recommendation?

The USPSTF recognizes that clinical decisions involve more considerations than evidence alone. Clinicians should understand the evidence but individualize
decision-making to the specific patient or situation.

School-aged children and adolescents younger than 18 years.

This recommendation is consistent with the 2013 USPSTF recommendation, with some key updates:
Adds a new I statement on interventions for the cessation of tobacco use in school-aged children and adolescents.
Includes e-cigarettes as a tobacco product.

What are other
relevant USPSTF
recommendations?

The USPSTF has made recommendations on behavioral and pharmacotherapy interventions for tobacco smoking cessation in
adults, including pregnant women, and primary care behavioral interventions to reduce illicit drug and nonmedical pharmaceutical
use in children and adolescents. These recommendations are available at https://www.uspreventiveservicestaskforce.org.

Definition of tobacco use: Tobacco use refers to any tobacco product, including cigarettes, cigars (including cigarillos and
little cigars), as well as vaping e-cigarettes.

1. Determine if youth are using tobacco.
2. If youth are not using tobacco:

Provide behavioral counseling interventions to all youth to prevent tobacco use.
Effective behavioral counseling interventions to prevent initiation of tobacco use include face-to-face

counseling, telephone counseling, and computer-based and print-based interventions.
3. If youth are using tobacco:

The evidence is insufficient to recommend for or against providing interventions to youth for cessation of tobacco use.
Existing studies on behavioral interventions to help youth quit tobacco use have been too heterogeneous and too

small to detect a benefit.
No medications are currently approved by the US Food and Drug Administration for tobacco cessation in children

and adolescents.
Use clinical judgment to decide how to best help youth who use tobacco.

Where to read the full
recommendation
statement?

Visit the USPSTF website (https://www.uspreventiveservicestaskforce.org) to read the full recommendation statement.
This includes more details on the rationale of the recommendation, including benefits and harms; supporting evidence;
and recommendations of others.

Provide interventions, including education or brief counseling, to prevent initiation of tobacco use.

School-aged children and adolescents who use tobacco: I statement
The evidence is insufficient to assess the balance of benefits and harms of primary carefeasible interventions for
cessation of tobacco use.

April 2020

USPSTF indicates US Preventive Services Task Force.

Clinical Review & Education US Preventive Services Task Force USPSTF Recommendation: Tobacco Use Prevention and Cessation in Children and Adolescents

1592 JAMA April 28, 2020 Volume 323, Number 16 (Reprinted) jama.com

2020 American Medical Association. All rights reserved.

Downloaded From: https://jamanetwork.com/ on 10/28/2022

http://www.jama.com/?utm_campaign=articlePDF%26utm_medium=articlePDFlink%26utm_source=articlePDF%26utm_content=jama.2020.4679

contain nicotine, which is the addictive ingredient in tobacco. Sub-
stances other than tobacco can also be used to smoke or vape.

Assessment of Risk
All youth are considered at risk of initiating tobacco use. Interven-
tions to prevent the initiation of tobacco use should be provided
to all youth who have not started using tobacco products yet,
regardless of the presence or absence of other risk factors. The
following risk factors may increase the risk of tobacco use in
youth: being male, white race, not college-bound, from a rural
area, having parents with lower levels of education, parental
smoking, having childhood friends who smoke, being an older
adolescent, experiencing highly stressful events, and perceiving
tobacco use as low risk.18,19

Interventions to Prevent Tobacco Use and Implementation
Considerations
Various behavioral counseling intervention types are effective in pre-
venting tobacco initiation in children, including face-to-face coun-
seling, telephone counseling, and computer-based and print-
based interventions.14

Individual interventions target specific audiences (the child/
adolescent, the parent, or both) and a variety of age ranges. For ex-
ample, in the reviewed studies,14 interventions for children aged 7
to 10 years tended to be print-based materials, whereas face-to-
face counseling and telephone- and computer-based interven-
tions typically targeted children older than 10 years. Interventions
targeting parents tended to be print- or telephone-based. The num-
ber of contacts made with intervention recipients also varied, rang-
ing from 1 to 8 contacts.14 The intensity of the interventions varied,
with the content of the print materials ranging from stickers to in-
formational newsletters or an activity book (for children) or activ-
ity guide (for parents). For telephone-based interventions, tele-
phone counseling was usually provided in conjunction with another

modality such as print materials or face-to-face counseling. Based
on the evidence reviewed,14 no specific component of behavioral
counseling interventions (such as intervention modality, target au-
dience, duration of intervention, or intervention setting) appeared
to make an intervention more or less effective. Thus, clinicians have
a broad range of effective behavioral counseling interventions from
which to choose. For additional information about behavioral coun-
seling interventions to prevent tobacco use, see Table 2, the Addi-
tional Tools and Resources section, and the Box.

Most of the evidence on behavioral counseling interventions
to prevent tobacco use focused on prevention of cigarette
smoking.14 Given the similar contextual and cultural issues cur-
rently surrounding the use of e-cigarettes in youth and the inclu-
sion of e-cigarettes as a tobacco product by the FDA, the USPSTF
concludes that the evidence on interventions to prevent cigarette
smoking could be applied to prevention of e-cigarette use as well.
The USPSTF also concludes that the evidence could be applied to
prevention of cigar use, which includes cigarillos and little cigars.

Additional Tools and Resources
Primary care clinicians may find the resources listed in the Box
useful in talking with children and adolescents about the harms of
tobacco use.

Other Related USPSTF Recommendations
The USPSTF has made recommendations on behavioral and phar-
macotherapy interventions for tobacco smoking cessation in adults,
including pregnant women,16 and primary care behavioral interven-
tions to reduce illicit drug and nonmedical pharmaceutical use in chil-
dren and adolescents.35

Table 2. Behavioral Counseling Interventions for Prevention of Tobacco Use in Children and Adolescentsa

Characteristic

Mode of intervention delivery

Print20-28 Face-to-face20,21,29-32 Telephone21,22,24,28-30 Computer21,31,33

Intervention
recipient

Child (aged 7-19 y), parent, or both Child (aged 11-19 y) or both
parent and child

Child (aged 9-17 y), parent, or both Child (aged
10-17 y)

Intervention
intensity

Variable. Included stickers,
newsletters, activity books,
or activity guides

1 to 8 visits 1 to 4 booster calls 1 to 6 sessions

Main intervention or part of
multimodal intervention

Always provided in conjunction with print
material or face-to-face counseling

Interactive or
web-based
programs

Examples of
materials
provided for
practiceb

Prescriptions with preprinted
antitobacco messages were given to
adolescents covering tobacco-free
offices, tobacco advertising, tobacco
and sports, smokeless tobacco,
nicotine and tobacco addiction,
p

SHOW MORE…

Book Review Assignment

Just follow the instruction for writing, read the text pdf carefully
(Read chapter 1-5) (read up to pages 76) for this assignment

Formatting
O 3 typed pages,single-space, 12pt font, Times New Roman, justified margins

Heading
O Include the bibliographic information of the article

Introduction
O Identify what your review intends to do
O Include the author & title again
O Include a very brief overview of the article, its purpose, & your reaction/evaluation

Background Information
O Place the article/book in context and discuss the criteria/reason
for judging the article/book

Summary
O Discuss the main points of the article/book, quoting & paraphrasing key
ideas from the author

Evaluation
O Your evaluation, consider the followingHow well the article/book achieves its goal
OWhat is the central lesson of the article/book
OWhat are the article/books strengths and shortcomings
OWhat personal experiences have you related to the subject

Conclusion
O Provide a final overview
O Suggested recommendations for further research
O Why this reading matters Liberalism and the Limits of Justice(1982; 2nd ed., 1998)

Liberalism and Its Critics, editor (1984)
Democracys Discontent: America in Search of a Public Philosophy (1996)

Public Philosophy: Essays on Morality in Politics (2005)
The Case Against Perfection: Ethics in the Age of Genetic Engineering (2007)

Justice: A Reader, editor (2007)

JUSTICE

WHATS
THE

RIGHT THING
TO DO?

MICHAEL J. SANDEL

FARRAR, STRAUS AND GIROUX

NEW YORK

For Kiku, with love

CONTENTS

DEDICATION
1. DOING THE RIGHT THING
2. THE GREATEST HAPPINESS PRINCIPLE / UTILITARIANISM
3. DO WE OWN OURSELVES? / LIBERTARIANISM
4. HIRED HELP / MARKETS AND MORALS
5. WHAT MATTERS IS THE MOTIVE / IMMANUEL KANT
6. THE CASE FOR EQUALITY / JOHN RAWLS
7. ARGUING AFFIRMATIVE ACTION
8. WHO DESERVES WHAT? / ARISTOTLE
9. WHAT DO WE OWE ONE ANOTHER? / DILEMMAS OF LOYALTY
10. JUSTICE AND THE COMMON GOOD

NOTES
ACKNOWLEDGMENTS
INDEX

1. DOING THE RIGHT THING

In the summer of 2004, Hurricane Charley roared out of the Gulf of Mexico and swept across Florida
to the Atlantic Ocean. The storm claimed twenty-two lives and caused $11 billion in damage. 1 It also left
in its wake a debate about price gouging.

At a gas station in Orlando, they were selling two-dollar bags of ice for ten dollars. Lacking power for
refrigerators or air-conditioning in the middle of August, many people had little choice but to pay up.
Downed trees heightened demand for chain saws and roof repairs. Contractors offered to clear two
trees off a homeowners rooffor $23,000. Stores that normally sold small household generators for
$250 were now asking $2,000. A seventy-seven-year-old woman fleeing the hurricane with her elderly
husband and handicapped daughter was charged $160 per night for a motel room that normally goes for
$40.2

Many Floridians were angered by the inflated prices. After Storm Come the Vultures, read a headline
in USA Today. One resident, told it would cost $10,500 to remove a fallen tree from his roof, said it was
wrong for people to try to capitalize on other peoples hardship and misery. Charlie Crist, the states
attorney general, agreed: It is astounding to me, the level of greed that someone must have in their soul
to be willing to take advantage of someone suffering in the wake of a hurricane.3

Florida has a law against price gouging, and in the aftermath of the hurricane, the attorney generals
office received more than two thousand complaints. Some led to successful lawsuits. A Days Inn in
West Palm Beach had to pay $70,000 in penalties and restitution for overcharging customers.4

But even as Crist set about enforcing the price-gouging law, some economists argued that the law
and the public outragewere misconceived. In medieval times, philosophers and theologians believed
that the exchange of goods should be governed by a just price, determined by tradition or the intrinsic
value of things. But in market societies, the economists observed, prices are set by supply and demand.
There is no such thing as a just price.

Thomas Sowell, a free-market economist, called price gouging an emotionally powerful but
economically meaningless expression that most economists pay no attention to, because it seems too
confused to bother with. Writing in the Tampa Tribune , Sowell sought to explain how price gouging
helps Floridians. Charges of price gouging arise when prices are significantly higher than what people
have been used to, Sowell wrote. But the price levels that you happen to be used to are not morally
sacrosanct. They are no more special or fair than other prices that market conditionsincluding
those prompted by a hurricanemay bring about.5

Higher prices for ice, bottled water, roof repairs, generators, and motel rooms have the advantage,
Sowell argued, of limiting the use of such things by consumers and increasing incentives for suppliers in
far-off places to provide the goods and services most needed in the hurricanes aftermath. If ice fetches
ten dollars a bag when Floridians are facing power outages in the August heat, ice manufacturers will
find it worth their while to produce and ship more of it. There is nothing unjust about these prices, Sowell
explained; they simply reflect the value that buyers and sellers choose to place on the things they
exchange.6

Jeff Jacoby, a pro-market commentator writing in the Boston Globe, argued against price-gouging
laws on similar grounds: It isnt gouging to charge what the market will bear. It isnt greedy or brazen.
Its how goods and services get allocated in a free society. Jacoby acknowledged that the price
spikes are infuriating, especially to someone whose life has just been thrown into turmoil by a deadly
storm. But public anger is no justification for interfering with the free market. By providing incentives for
suppliers to produce more of the needed goods, the seemingly exorbitant prices do far more good than
harm. His conclusion: Demonizing vendors wont speed Floridas recovery. Letting them go about their
business will.7

Attorney General Crist (a Republican who would later be elected governor of Florida) published an op-
ed piece in the Tampa paper defending the law against price gouging: In times of emergency,
government cannot remain on the sidelines while people are charged unconscionable prices as they flee

for their lives or seek the basic commodities for their families after a hurricane.8 Crist rejected the
notion that these unconscionable prices reflected a truly free exchange:

This is not the normal free market situation where willing buyers freely elect to enter into the
marketplace and meet willing sellers, where a price is agreed upon based on supply and
demand. In an emergency, buyers under duress have no freedom. Their purchases of
necessities like safe lodging are forced.9

The debate about price gouging that arose in the aftermath of Hurricane Charley raises hard
questions of morality and law: Is it wrong for sellers of goods and services to take advantage of a
natural disaster by charging whatever the market will bear? If so, what, if anything, should the law do
about it? Should the state prohibit price gouging, even if doing so interferes with the freedom of buyers
and sellers to make whatever deals they choose?

Welfare, Freedom, and Virtue

These questions are not only about how individuals should treat one another. They are also about what
the law should be, and about how society should be organized. They are questions about justice. To
answer them, we have to explore the meaning of justice. In fact, weve already begun to do so. If you
look closely at the price-gouging debate, youll notice that the arguments for and against price-gouging
laws revolve around three ideas: maximizing welfare, respecting freedom, and promoting virtue. Each of
these ideas points to a different way of thinking about justice.

The standard case for unfettered markets rests on two claimsone about welfare, the other about
freedom. First, markets promote the welfare of society as a whole by providing incentives for people to
work hard supplying the goods that other people want. (In common parlance, we often equate welfare
with economic prosperity, though welfare is a broader concept that can include noneconomic aspects of
social well-being.) Second, markets respect individual freedom; rather than impose a certain value on
goods and services, markets let people choose for themselves what value to place on the things they
exchange.

Not surprisingly, the opponents of price-gouging laws invoke these two familiar arguments for free
markets. How do defenders of price gouging laws respond? First, they argue that the welfare of society
as whole is not really served by the exorbitant prices charged in hard times. Even if high prices call forth
a greater supply of goods, this benefit has to be weighed against the burden such prices impose on
those least able to afford them. For the affluent, paying inflated prices for a gallon of gas or a motel
room in a storm may be an annoyance; but for those of modest means, such prices pose a genuine
hardship, one that might lead them to stay in harms way rather than flee to safety. Proponents of price-
gouging laws argue that any estimate of the general welfare must include the pain and suffering of those
who may be priced out of basic necessities during an emergency.

Second, defenders of price-gouging laws maintain that, under certain conditions, the free market is
not truly free. As Crist points out, buyers under duress have no freedom. Their purchases of
necessities like safe lodging are forced. If youre fleeing a hurricane with your family, the exorbitant
price you pay for gas or shelter is not really a voluntary exchange. Its something closer to extortion. So
to decide whether price-gouging laws are justified, we need to assess these competing accounts of
welfare and of freedom.

But we also need to consider one further argument. Much public support for price-gouging laws comes
from something more visceral than welfare or freedom. People are outraged at vultures who prey on
the desperation of others and want them punishednot rewarded with windfall profits. Such sentiments
are often dismissed as atavistic emotions that should not interfere with public policy or law. As Jacoby
writes, demonizing vendors wont speed Floridas recovery.10

But the outrage at price-gougers is more than mindless anger. It gestures at a moral argument worth
taking seriously. Outrage is the special kind of anger you feel when you believe that people are getting
things they dont deserve. Outrage of this kind is anger at injustice.

Crist touched on the moral source of the outrage when he described the greed that someone must

have in their soul to be willing to take advantage of someone suffering in the wake of a hurricane. He
did not explicitly connect this observation to price-gouging laws. But implicit in his comment is something
like the following argument, which might be called the virtue argument:

Greed is a vice, a bad way of being, especially when it makes people oblivious to the suffering of
others. More than a personal vice, it is at odds with civic virtue. In times of trouble, a good society pulls
together. Rather than press for maximum advantage, people look out for one another. A society in which
people exploit their neighbors for financial gain in times of crisis is not a good society. Excessive greed
is therefore a vice that a good society should discourage if it can. Price-gouging laws cannot banish
greed, but they can at least restrain its most brazen expression, and signal societys disapproval of it.
By punishing greedy behavior rather than rewarding it, society affirms the civic virtue of shared sacrifice
for the common good.

To acknowledge the moral force of the virtue argument is not to insist that it must always prevail over
competing considerations. You might conclude, in some instances, that a hurricane-stricken community
should make a devils bargainallow price gouging in hopes of attracting an army of roofers and
contractors from far and wide, even at the moral cost of sanctioning greed. Repair the roofs now and
the social fabric later. Whats important to notice, however, is that the debate about price-gouging laws
is not simply about welfare and freedom. It is also about virtueabout cultivating the attitudes and
dispositions, the qualities of character, on which a good society depends.

Some people, including many who support price-gouging laws, find the virtue argument discomfiting.
The reason: It seems more judgmental than arguments that appeal to welfare and freedom. To ask
whether a policy will speed economic recovery or spur economic growth does not involve judging
peoples preferences. It assumes that everyone prefers more income rather than less, and it doesnt
pass judgment on how they spend their money. Similarly, to ask whether, under conditions of duress,
people are actually free to choose doesnt require evaluating their choices. The question is whether, or
to what extent, people are free rather than coerced.

The virtue argument, by contrast, rests on a judgment that greed is a vice that the state should
discourage. But who is to judge what is virtue and what is vice? Dont citizens of pluralist societies
disagree about such things? And isnt it dangerous to impose judgments about virtue through law? In the
face of these worries, many people hold that government should be neutral on matters of virtue and
vice; it should not try to cultivate good attitudes or discourage bad ones.

So when we probe our reactions to price gouging, we find ourselves pulled in two directions: We are
outraged when people get things they dont deserve; greed that preys on human misery, we think, should
be punished, not rewarded. And yet we worry when judgments about virtue find their way into law.

This dilemma points to one of the great questions of political philosophy: Does a just society seek to
promote the virtue of its citizens? Or should law be neutral toward competing conceptions of virtue, so
that citizens can be free to choose for themselves the best way to live?

According to the textbook account, this question divides ancient and modern political thought. In one
important respect, the textbook is right. Aristotle teaches that justice means giving people what they
deserve. And in order to determine who deserves what, we have to determine what virtues are worthy
of honor and reward. Aristotle maintains that we cant figure out what a just constitution is without first
reflecting on the most desirable way of life. For him, law cant be neutral on questions of the good life.

By contrast, modern political philosophersfrom Immanuel Kant in the eighteenth century to John
Rawls in the twentieth centuryargue that the principles of justice that define our rights should not rest
on any particular conception of virtue, or of the best way to live. Instead, a just society respects each
persons freedom to choose his or her own conception of the good life.

So you might say that ancient theories of justice start with virtue, while modern theories start with
freedom. And in the chapters to come, we explore the strengths and weaknesses of each. But its worth
noticing at the outset that this contrast can mislead.

For if we turn our gaze to the arguments about justice that animate contemporary politicsnot among
philosophers but among ordinary men and womenwe find a more complicated picture. Its true that
most of our arguments are about promoting prosperity and respecting individual freedom, at least on the
surface. But underlying these arguments, and sometimes contending with them, we can often glimpse
another set of convictionsabout what virtues are worthy of honor and reward, and what way of life a
good society should promote. Devoted though we are to prosperity and freedom, we cant quite shake
off the judgmental strand of justice. The conviction that justice involves virtue as well as choice runs

deep. Thinking about justice seems inescapably to engage us in thinking about the best way to live.

What Wounds Deserve the Purple Heart?

On some issues, questions of virtue and honor are too obvious to deny. Consider the recent debate
over who should qualify for the Purple Heart. Since 1932, the U.S. military has awarded the medal to
soldiers wounded or killed in battle by enemy action. In addition to the honor, the medal entitles
recipients to special privileges in veterans hospitals.

Since the beginning of the current wars in Iraq and Afghanistan, growing numbers of veterans have
been diagnosed with post-traumatic stress disorder and treated for the condition. Symptoms include
recurring nightmares, severe depression, and suicide. At least three hundred thousand veterans
reportedly suffer from traumatic stress or major depression. Advocates for these veterans have
proposed that they, too, should qualify for the Purple Heart. Since psychological injuries can be at least
as debilitating as physical ones, they argue, soldiers who suffer these wounds should receive the
medal.11

After a Pentagon advisory group studied the question, the Pentagon announced, in 2009, that the
Purple Heart would be reserved for soldiers with physical injuries. Veterans suffering from mental
disorders and psychological trauma would not be eligible, even though they qualify for government-
supported medical treatment and disability payments. The Pentagon offered two reasons for its
decision: traumatic stress disorders are not intentionally caused by enemy action, and they are difficult
to diagnose objectively.12

Did the Pentagon make the right decision? Taken by themselves, its reasons are unconvincing. In the
Iraq War, one of the most common injuries recognized with the Purple Heart has been a punctured
eardrum, caused by explosions at close range.13 But unlike bullets and bombs, such explosions are not
a deliberate enemy tactic intended to injure or kill; they are (like traumatic stress) a damaging side effect
of battlefield action. And while traumatic disorders may be more difficult to diagnose than a broken limb,
the injury they inflict can be more severe and long-lasting.

As the wider debate about the Purple Heart revealed, the real issue is about the meaning of the medal
and the virtues it honors. What, then, are the relevant virtues? Unlike other military medals, the Purple
Heart honors sacrifice, not bravery. It requires no heroic act, only an injury inflicted by the enemy. The
question is what kind of injury should count.

A veterans group called the Military Order of the Purple Heart opposed awarding the medal for
psychological injuries, claiming that doing so would debase the honor. A spokesman for the group
stated that shedding blood should be an essential qualification.14 He didnt explain why bloodless
injuries shouldnt count. But Tyler E. Boudreau, a former Marine captain who favors including
psychological injuries, offers a compelling analysis of the dispute. He attributes the opposition to a
deep-seated attitude in the military that views post-traumatic stress as a kind of weakness. The same
culture that demands tough-mindedness also encourages skepticism toward the suggestion that the
violence of war can hurt the healthiest of minds . . . Sadly, as long as our military culture bears at least a
quiet contempt for the psychological wounds of war, it is unlikely those veterans will ever see a Purple
Heart.15

So the debate over the Purple Heart is more than a medical or clinical dispute about how to determine
the veracity of injury. At the heart of the disagreement are rival conceptions of moral character and
military valor. Those who insist that only bleeding wounds should count believe that post-traumatic
stress reflects a weakness of character unworthy of honor. Those who believe that psychological
wounds should qualify argue that veterans suffering long-term trauma and severe depression have
sacrificed for their country as surely, and as honorably, as those whove lost a limb.

The dispute over the Purple Heart illustrates the moral logic of Aristotles theory of justice. We cant
determine who deserves a military medal without asking what virtues the medal properly honors. And to
answer that question, we have to assess competing conceptions of character and sacrifice.

It might be argued that military medals are a special case, a throwback to an ancient ethic of honor
and virtue. These days, most of our arguments about justice are about how to distribute the fruits of
prosperity, or the burdens of hard times, and how to define the basic rights of citizens. In these domains,

considerations of welfare and freedom predominate. But arguments about the rights and wrongs of
economic arrangements often lead us back to Aristotles question of what people morally deserve, and
why.

Bailout Outrage

The public furor over the financial crisis of 200809 is a case in point. For years, stock prices and real
estate values had climbed. The reckoning came when the housing bubble burst. Wall Street banks and
financial institutions had made billions of dollars on complex investments backed by mortgages whose
value now plunged. Once proud Wall Street firms teetered on the edge of collapse. The stock market
tanked, devastating not only big investors but also ordinary Americans, whose retirement accounts lost
much of their value. The total wealth of American families fell by $11 trillion in 2008, an amount equal to
the combined annual output of Germany, Japan, and the UK.16

In October 2008, President George W. Bush asked Congress for $700 billion to bail out the nations
big banks and financial firms. It didnt seem fair that Wall Street had enjoyed huge profits during the good
times and was now asking taxpayers to foot the bill when things had gone bad. But there seemed no
alternative. The banks and financial firms had grown so vast and so entwined with every aspect of the
economy that their collapse might bring down the entire financial system. They were too big to fail.

No one claimed that the banks and investment houses deserved the money. Their reckless bets
(enabled by inadequate government regulation) had created the crisis. But here was a case where the
welfare of the economy as a whole seemed to outweigh considerations of fairness. Congress
reluctantly appropriated the bailout funds.

Then came the bonuses. Shortly after the bailout money began to flow, news accounts revealed that
some of the companies now on the public dole were awarding millions of dollars in bonuses to their
executives. The most egregious case involved the American International Group (A.I.G.), an insurance
giant brought to ruin by the risky investments of its financial products unit. Despite having been rescued
with massive infusions of government funds (totaling $173 billion), the company paid $165 million in
bonuses to executives in the very division that had precipitated the crisis. Seventy-three employees
received bonuses of $1 million or more.17

News of the bonuses set off a firestorm of public protest. This time, the outrage was not about ten-
dollar bags of ice or overpriced motel rooms. It was about lavish rewards subsidized with taxpayer funds
to members of the division that had helped bring the global financial system to near meltdown.
Something was wrong with this picture. Although the U.S. government now owned 80 percent of the
company, the treasury secretary pleaded in vain with A.I.G.s government-appointed CEO to rescind the
bonuses. We cannot attract and retain the best and the brightest talent, the CEO replied, if employees
believe their compensation is subject to continued and arbitrary adjustment by the U.S. Treasury. He
claimed the employees talents were needed to unload the toxic assets for the benefit of the taxpayers,
who, after all, owned most of the company.18

The public reacted with fury. A full-page headline in the tabloid New York Post captured the sentiments
of many: Not So Fast You Greedy Bastards.19 The U.S. House of Representatives sought to claw
back the payments by approving a bill that would impose a 90 percent tax on bonuses paid to
employees of companies that received substantial bailout funds.20 Under pressure from New York
attorney general Andrew Cuomo, fifteen of the top twenty A.I.G. bonus recipients agreed to return the
payments, and some $50 million was recouped in all.21 This gesture assuaged public anger to some
degree, and support for the punitive tax measure faded in the Senate.22 But the episode left the public
reluctant to spend more to clean up the mess the financial industry had created.

At the heart of the bailout outrage was a sense of injustice. Even before the bonus issue erupted,
public support for the bailout was hesitant and conflicted. Americans were torn between the need to
prevent an economic meltdown that would hurt everyone and their belief that funneling massive sums to
failed banks and investment companies was deeply unfair. To avoid economic disaster, Congress and
the public acceded. But morally speaking, it had felt all along like a kind of extortion.

Underlying the bailout outrage was a belief about moral desert: The executives receiving the bonuses

(and the companies receiving the bailouts) didnt deserve them. But why didnt they? The reason may be
less obvious than it seems. Consider two possible answersone is about greed, the other about failure.

One source of outrage was that the bonuses seemed to reward greed, as the tabloid headline
indelicately suggested. The public found this morally unpalatable. Not only the bonuses but the bailout as
a whole seemed, perversely, to reward greedy behavior rather than punish it. The derivatives traders
had landed their company, and the country, in dire financial perilby making reckless investments in
pursuit of ever-greater profits. Having pocketed the profits when times were good, they saw nothing
wrong with million-dollar bonuses even after their investments had come to ruin.23

The greed critique was voiced not only by the tabloids, but also (in more decorous versions) by public
officials. Senator Sherrod Brown (D-Ohio) said that A.I.G.s behavior smacks of greed, arrogance, and
worse.24 President Obama stated that A.I.G. finds itself in financial distress due to recklessness and
greed.25

The problem with the greed critique is that it doesnt distinguish the rewards bestowed by the bailout
after the crash from the rewards bestowed by markets when times were flush. Greed is a vice, a bad
attitude, an excessive, single-minded desire for gain. So its understandable that people arent keen to
reward it. But is there any reason to assume that the recipients of bailout bonuses are any greedier now
than they were a few years ago, when they were riding high and reaping even greater rewards?

Wall Street traders, bankers, and hedge fund managers are a hard-charging lot. The pursuit of
financial gain is what they do for a living. Whether or not their vocation taints their character, their virtue
is unlikely to rise or fall with the stock market. So if its wrong to reward greed with big bailout bonuses,
isnt it also wrong to reward it with market largess? The public was outraged when, in 2008, Wall Street
firms (some on taxpayer-subsidized life support) handed out $16 billion in bonuses. But this figure was
less than half the amounts paid out in 2006 ($34 billion) and 2007 ($33 billion).26 If greed is the reason
they dont deserve the money now, on what basis can it be said they deserved the money then?

One obvious difference is that bailout bonuses come from the taxpayer while the bonuses paid in
good times come from company earnings. If the outrage is based on the conviction that the bonuses are
undeserved, however, the source of the payment is not morally decisive. But it does provide a clue: the
reason the bonuses are coming from the taxpayer is that the companies have failed. This takes us to
the heart of the complaint. The American publics real objection to the bonusesand the bailoutis not
that they reward greed but that they reward failure.

Americans are harder on failure than on greed. In market-driven societies, ambitious people are
expected to pursue their interests vigorously, and the line between self-interest and greed often blurs.
But the line between success and failure is etched more sharply. And the idea that people deserve the
rewards that success bestows is central to the American dream.

Notwithstanding his passing reference to greed, President Obama understood that rewarding failure
was the deeper source of dissonance and outrage. In announcing limits on executive pay at companies
receiving bailout funds, Obama identified the real source of bailout outrage:

This is America. We dont disparage wealth. We dont begrudge anybody for achieving
success. And we certainly believe that success should be rewarded. But what gets people
upsetand rightfully soare executives being rewarded for failure, especially when those
rewards are subsidized by U.S. taxpayers.27

One of the most bizarre statements about bailout ethics came from Senator Charles Grassley (R-Iowa),
a fiscal conservative from the heartland. At the height of the bonus furor, Grassley said in an Iowa radio
interview that what bothered him most was the refusal of the corporate executives to take any blame for
their failures. He would feel a bit better towards them if they would follow the Japanese example and
come before the American people and take that deep bow and say, Im sorry, and then either do one of
two thingsresign or go commit suicide.28

Grassley later explained that he was not calling on the executives to commit suicide. But he did want
them to accept responsibility for their failure, to show contrition, and to offer a public apology. I havent
heard this from CEOs, and it just makes it very difficult for the taxpayers of my district to just keep
shoveling money out the door.29

Grassleys comments support my hunch that the bailout anger was not mainly about greed; what most
offended Americans sense of justice was that their tax dollars were being used to reward failure.

If thats right, it remains to ask whether this view of the bailouts was justified. Were the CEOs and top
executives of the big banks and investment firms really to blame for the financial crisis? Many of the
executives didnt think so. Testifying before congressional committees investigating the financial crisis,
they insisted they had done all they could with the information available to them. The former chief
executive of Bear Stearns, a Wall Street investment firm that collapsed in 2008, said hed pondered
long and hard whether he could have done anything differently. He concluded hed done all he could. I
just simply have not been able to come up with anything . . . that would have made a difference to the
situation we faced.30

Other CEOs of failed companies agreed, insisting that they were victims of a financial tsunami
beyond their control.31 A similar attitude extended to young traders, who had a hard time understanding
the publics fury about their bonuses. Theres no sympathy for us anywhere, a Wall Street trader told a
reporter for Vanity Fair. But its not as if we werent working hard.32

The tsunami metaphor became part of bailout vernacular, especially in financial circles. If the
executives are right that the failure of their companies was due to larger economic forces, not their own
decisions, this would explain why they didnt express the remorse that Senator Grassley wanted to hear.
But it also raises a far-reaching question about failure, success, and justice.

If big, systemic economic forces account for the disastrous loses of 2008 and 2009, couldnt it be
argued that they also account for the dazzling gains of earlier years? If the weather is to blame for the
bad years, how can it be that the talent, wisdom, and hard work of bankers, traders, and Wall Street
executives are responsible for the stupendous returns that occurred when the sun was shining?

Confronted with public outrage over paying bonuses for failure, the CEOs argued that financial returns
are not wholly their own doing, but the product of forces beyond their control. They may have a point.
But if this is true, theres good reason to question their claim to out-sized compensation when times are
good. Surely the end of the cold war, the globalization of trade and capital markets, the rise of personal
computers and the Internet, and a host of other factors help explain the success of the financial industry
during its run in the 1990