Jim A. Kuypers and Ashley Gellert
In this study we use a dramatistic perspective to explore the absence of guilt as a determining factor of the continued hierarchical destruction in the Martin Luther King, Jr./Charles R. Drew Medical Center. This public hospital’s history of patient mortality dilemmas was featured in the Pulitzer Prize-winning public service series authored by the Los Angeles Times staff. We examine the hierarchical relationships within the hospital especially in terms of Kenneth Burke’s trio of guilt, purification, and redemption. We found that without recognition of guilt and fitting purification, redemption remained out of reach, and the polluted hierarchy further grew.
THE PULITZER PRIZE IN JOURNALISM is widely recognized as the ultimate award for journalistic excellence. Among these total awards the prize’s three oldest categories stand out: editorial writing, public service, and reporting. The public service category is of special interest since these series exhibit not only excellence in writing quality, thus making for fine reading, but have frequently served to inspire the public in such a way that societal change is enacted. Recent winners have included the “exposure of the high death rate among construction workers on the Las Vegas Strip amid lax enforcement of regulations, leading to changes in policy”, the “mistreatment of wounded veterans at Walter Reed Hospital, evoking a national outcry and producing reforms”, and a “comprehensive probe into backdated stock options for business executives that triggered investigations, the ouster of top officials and widespread change in corporate America.”1 Although not all winners exhibit a series of stories culminating in some type of action or shift in societal thinking, this pattern—excellence in reporting dramatically exposing a societal ill followed by reform—is present in an overwhelming number of articles, particularly those written since the 1970s.
To better understand the rich rhetorical culture the Pulitzer Prize in public service represents, we examine a series of 2004 Los Angeles Times prize-winning articles regarding medical malpractice and patient mortality issues at Martin Luther King, Jr./Charles R. Drew Medical Center in South Los Angeles. Although the articles, if separated, could be viewed as “disconnected bits of discourse,”2 their status as a series unites them and, when combined with their plotlines of hierarchical dilemmas, creates a rhetorical effort ripe for study from a dramatistic point of view.
Of particular note, these articles present a major exception to the pattern of exposure/action found in the majority of public service winners. Instead, the King/Drew articles exhibit all the elements of a major societal drama, but, subsequent to their publication, no real action surrounding King/Drew occurred; far from it, the situation persisted, eventuating with the hospital’s closing in 2007. Intrigued by this, we sought to discover how the authors of the article series could write in such a manner to receive a Pulitzer, yet also write in such a manner that their exposure of a gross societal ill was unable to motivate South Los Angeles’ community members, hospital staff, and supervisors to societal action and redemption.
In order to better understand the relationships among the journalists, the community, King/Drew hospital, and the lack of action regarding the hospital’s history of medical inadequacies, we employ a two-tiered pentadic analysis to explore both the journalists’ motives underpinning the news series and the King/Drew world they create. Few studies have examined news articles from a Burkean perspective. Two examples include Brian L. Ott and Eric Aoki’s framing analysis of Matthew Shephard’s murder3 and Daron Williams and Jim A. Kuypers’ pentadic analysis of NASCAR driver interviews.4 These studies examine journalists’ influence on story content and agents within news coverage, respectively, as separate elements. In this study, however, we unite these two elements to evaluate journalists’ role as agents in writing this news series, then also examine, in terms of story content, how the King/Drew agents function in the scene the journalists construct.
Following a brief discussion of how we use dramatism in this essay, we move to our actual analysis. The first portion of the analysis is external in orientation because it considers the journalists’ role as agent within the overall situation and their use of the news series as a means to provide residents of South Los Angeles with reformed healthcare. The second portion of the analysis is internal in orientation because it considers the hospital’s situation as mediated and constructed through the journalists’ act of writing the news series. Finally, we unite the external analysis of the journalists’ agenda for writing the news series and the internal analysis of the journalists’ constructed situation within the King/Drew hospital. This allows us to explore the dramatistic cycle inherent within the overall situation; we are thus able to explore the journalists’ act of writing the news series and, as a result, see how they created a scenic motive that actually perpetuated the very acts that occasioned the writing of the articles in the first place. We feel that this reconstructed scene hampered efforts of the public and hospital agents to move through the cycle of redemption. Importantly, then, the journalists’ act of writing the series thwarted the dramatistic cycle and the societal action that Pulitzer Prize-winning public service articles aim to achieve.
As Burke explains, “Dramatism is a method of analysis and a corresponding critique of terminology designed to show that the most direct route to the study of human relations…is via a methodical inquiry into cycles…and their functions.”5 In this essay, we view dramatism as the study of the hierarchies within society and the subsequent actions of the people within those hierarchies as they build relationships, acquire responsibilities, accept or reject their positions, and strengthen or destroy the structure. This rhetorical perspective explores drama through language, specifically how language becomes a form of action for people within hierarchies. According to Bernard L. Brock, Robert L. Scott, and James W. Chesebro, “hierarchy generates the structure of our dramatic society. In society, the social, economic, and political powers are unevenly divided. Power endows individuals with authority. Authority, in turn, establishes definite relationships among people, reflecting how much power they possess.” 6 Given this power distribution inherent within society, Burke notes that the formation of hierarchies is “inevitable.”7
Just as hierarchies are inevitable within society, so is the struggle over power within them. C. Allen Carter warns that as people within hierarchies “consolidate their…position by asserting themselves over those beneath them…abuse of power is endemic.”8 He continues to remind us that “power corrupts, and absolute power corrupts absolutely those goaded by the hierarchical order” because people are always working to achieve new positions and thus new levels of power and responsibility within a hierarchy.9 This hierarchy, along with its resulting distribution of power, forms a type of societal pyramid with different layers of people in varying positions stacked upon each other with the few most powerful on top and those with less power at the bottom. People have different responsibilities to themselves and others surrounding them depending upon their position within this intricate societal structure. The relationships that people build with others on different hierarchical levels internally cement the structure. Once given a place within the hierarchy, we can choose to accept or reject not just that position but also the relationships and the personal and interpersonal responsibilities that accompany that position.
With acceptance, the structure remains strong and unified,but “when people reject the traditional hierarchy,” write Brock, Scott, and Chesebro, “they ‘fall’ and thereby acquire a feeling of guilt.”10 Be that as it may, Edward C. Appel notes that guilt can also be the result of not working to “improve or at least maintain [the] social and ethical standing” that accompanies one’s position within a given hierarchy.11 With this guilt comes the need to purify through mortification, “self-sacrifice that relieves guilt,” or victimage, “the purging of guilt through a scapegoat that symbolizes society’s guilt.”12 Burke views this dramatic form, in a large sense, with humans “in principle in revolt against the principle of authority. This condition is indigenous to the nature of the idea of Order.”13 Burke sees victimage as a natural response to guilt, where humans act and do not think about how their rejection of the hierarchy led to their guilt.14 He also finds that “the compensatory sacrifice of a ritually perfect victim would be the corresponding ‘norm.’ Hence, insofar as the religious pattern (of ‘original sin’ and sacrificial redeemer) is adequate to the ‘cathartic’ needs of a human hierarchy . . . it would follow that the promoting of social cohesion through victimage is ‘normal’ and ‘natural’.”15
Although the guilty have two purification options, Rise Jane Samra is quick to note that the type and magnitude of purification expressed must fit the magnitude of the rejection. She writes that, “the act of purification must be appropriate to the sin of the guilty for the drama to succeed as an act of redemption.”16 Redemption is achieved when the purification of the guilty matches the magnitude of his or her rejection, and when society’s perception of the actions of the guilty are reset. Burke explains the function of guilt, purification, and redemption in terms of a system, or “perfect mechanism,” of many parts where each piece is integral to the function of the whole.17 This speaks to the complementary nature of rejection and purification, and the crucial need to achieve redemption in order to allow the mechanism to function. If just one element from this system is absent, then the mechanism will stop, or continuously cycle through guilt and attempts at purification until either redemption is achieved or the hierarchy crumbles from within.
Sometimes, critics can help to re-build a hierarchy by exploring what events have weakened it and by concurrently determining what types of relationships and events would strengthen it. Brock writes that critics working to achieve this hierarchical reconstruction “can explore efforts to transform the hierarchy with an eye toward strengthening them and bringing them to full fruition in…relationships that better promote justice.” Additionally, he notes that through such exploration, “motives that perpetuate social inequality can be transformed into motives that perform social justice.” 18 Brock also acknowledges that critics do not always revitalize a hierarchy because new relationships that emerge might not serve to generate social justice for the people who inhabit that hierarchy. Although Burke writes that hierarchies are “inevitable,” he is quick to note that this does not mean “that any particular hierarchy is inevitable; the crumbling of hierarchies is as true a fact about them as their formation.”19 We believe that the Los Angeles Times journalists who authored the Pulitzer Prize-winning series can be viewed as the critic about whom Brock writes because of their efforts to expose the problems that plagued the King/Drew hierarchy through their news series. Ultimately, the scene and relationships the journalists revealed prevented them, having been agents, from revitalizing the hierarchy from within. Once a hierarchy crumbles, no social action will be able to repair that societal structure.
Burke believed that drama was everywhere, that people’s lives were “saturated” with dramatic language and action.20 The Martin Luther King, Jr./Charles R. Drew Medical Center situation is just such an example. King/Drew serviced the minority communities in South Los Angeles—once primarily black, now predominantly Latino—many of whom are unemployed with 36% living below the poverty level.21 The hospital was born from the 1965 Watts race riots, where then South ‘Central’ Los Angeles’ residents demanded equality in basic aspects of daily living. A study of the riot’s causes found that the residents saw a great need for quality, accessible healthcare for the local minority population.22 Days after Martin Luther King, Jr.’s assassination, ground broke for the medical center; seven years after the Watts riots, King/Drew opened its doors.23 It is named in honor of Dr. King and Dr. Charles R. Drew, who helped develop blood banks in the United States following World War II.24 Despite its residents’ and namesakes’ hope for equality, the dream was eventually deferred by employee negligence, charges of nepotism, graft, medical malpractice, and avoidable patient deaths.
For 32 years, patients died at the hands of nurses and doctors because of careless medical mistakes. Many of these incidents would be buried along with the patients through waivers and the blind eyes of the hospital supervisors. However, these secrets were exhumed in 2004 in a series written by the Los Angeles Times regarding the hospital’s history of dilemmas, patient stories, grief, and loss. Two consistent themes unite the articles within the series: the need for the guilty to take responsibility and redeem themselves in the eyes of the South Los Angeles residents, and the persistent need for quality, affordable healthcare. The latter issue helped to ignite the 1965 riots led by the community’s minority population and, once again, called residents to the picket lines. This time, however, it was to demand support for a hospital that provided them with healthcare services that were both desperately needed and responsible for killing their family members, friends, and neighbors.25
If we look at the Prize winners in the public service category, it is safe to assume that the King/Drew series was meant to serve as a call to action for community members and health officials to finally solve the hospital’s patient care dilemmas. Within this series, the journalists could encourage community members and the hospital’s staff to reform their actions to better support the hospital’s purpose of healing and serving the community, and thus working against its current actions that resulted in gross medical malpractice suits. Yet, because of the conflict between the journalists’ efforts to reconstruct the scene within the hospital to achieve social change and the ultimate role that such scenes played in overwhelming and masking the agents responsible for the hospital’s state, we are inclined to believe that the public and hospital’s agents were never able to respond to the action the series prescribed. In short, our journalist agents’ act was to write the series with the purpose of producing a mechanism of change within the societal hierarchy. Looked at Dramatistically, this externally understood act-purpose ratio dominated the situation and would seem to suggest the potential for a positive response regarding King/Drew. This changes considerably when one examines the scene that the journalists actually created through their stories; that is to say, from an internal point of view.
When considered in terms of Burke’s pentad, three clusters of agents arise in the dramatistic world that journalists from the Los Angeles Times created: supervisors, doctors, and nurses. These agents are responsible for caring for the hospital’s patients, providing actions that would reinforce the hospital’s purpose of healing and serving South Los Angeles’ minority community. Of major concern in the series, however, was the perversion of this purpose—the hierarchical confusion, lack of supervision, and gross medical malpractice. However, the purpose and disordered hierarchy, though accurate and well constructed by the journalists, was rendered impotent through the journalists’ construction of the agents responsible for the King/Drew situation. The stories, viewed collectively as the journalists’ act, constructed agents of the hospital who, in speaking with their own voices, focused not on purpose or redemption, but instead created an overwhelming, chaotic scene. The result of this dramatic world is a scene that reinforces the King/Drew agents’ dangerous actions and prevents the hospital from achieving its purpose in the community.
Supervisors’ Role as Agents
Five supervisors comprise the first cluster of agents in King/Drew: Yvonne Brathwaite Burke, Gloria Molina, Zev Yaroslavsky, Michael Antonovich, and Don Knabe. They are responsible for governing the hospital.26 It is their job to remain updated with employee discipline, medical malpractice, and personnel issues, in addition to ensuring that the hospital meets accreditation standards and receives necessary funding. Because of their role as hospital overseers, they have received much of the blame for allowing King/Drew to reach the state of woeful inadequacy in terms of healthcare, employee relations, and mortality rates. Also known as the “little kings,” this group is responsible for establishing and enforcing laws and regulations for, in this case, the King/Drew hospital and its employees. According to one reporter, the supervisors “are both the executive and legislative branches of county government which gives them broad powers with few checks and balances.”27
Such limited regulations create issues for the supervisors, hospital, and employees when the supervisors create rules—including the need for them to be kept current with doctors’ and medical staff’s malpractice issues, the consequences for which are punishments at work and reports to the Department of Health Services—but do not follow through with such consequences. For example, just one doctor in a five-year time span, from 1999-2004, was reported to a disciplinary committee; however, numerous patients died from medical staff negligence within that same time frame.28 This is just one example of the consequences resulting from the hospital’s governing system, but it continued to occur as the hospital had yet to learn from its mistakes.
The supervisors were portrayed as making claims that they were not updated on new medical malpractice, negligence, and disciplinary issues among the hospital’s staff. For example, Burke was quoted as stating that, “We have not had the information that there were these kinds of problems,” problems that Molina deemed “astounding,” after government inspectors accused the hospital of negligent patient care in 2003.29 Yaroslavsky expressed similar surprise, demanding to know why he and his fellow supervisors were not told “that [King/Drew] was going to hell in a handbasket.”30 But the Los Angeles Times reporters reveal that the supervisors were told, for if they were not so informed the hospital would not have been able to settle malpractice suits brought against it and its employees by patients and their families.31 Since King/Drew spent $20.1 million on such suits between 1999 and 2003, we feel there is little merit to the supervisors’ claims, and yet, the supervisors were ultimately portrayed as operating out of a sense of ignorance. 32
Due to the investigations the supervisors finally realized the correlation between inaction with staff disciplinary problems and the accumulation of patient care dilemmas. They had two choices: make serious changes to the hospital in an effort to curb patient fatalities and injuries, or continue to allow the hospital’s doctors to get away with gross malpractice. The supervisors chose the former and, in addition to hiring consultants and health department managers to investigate the hospital’s problems, they decided to close the trauma, radiology, and neonatal care units to afford more time repairing the damage in the hospital’s remaining units.33
Some believed the efforts made were minimal, the easy first steps to achieving a lofty, integral goal. For example, Connie Rice, a Los Angeles civil rights attorney, stated that she does not want King/Drew to “bring in this consultant to do tooth whitening and flossing [when] we need root canals and dental implants.” Rice called for greater enforcement of the new rules the consultants might have suggested and stronger measures that truly ensured patient safety and progress.34 But others, like Fred Leaf, Department of Heath Services Chief Operations Officer, are pleased by King/Drew’s efforts to make the hospital a safe place for patients to receive medical treatment. Leaf acknowledged the situation, stating that, “obviously, something like this is terrible,” then continued by suggesting a positive aspect to the situation noting that community members “can believe, you can bet, that every time something occurs, safety process doubles. . . . I think we’re doing everything we can to assure there’s a safe environment.”35
Supervisor Burke agrees that “considerable work” has begun on restructuring the hospital to ensure patient safety. Yaroslavsky further considers this work as “a major step…a beginning at MLK.”36 However, with such a long history of negligent patient care, Burke is unsure of how long such a process will take. Furthermore, she admits that she does not “know that you can correct all of the problems from 25 years in three months. It’s going to take awhile because there’s still a lot of people to be removed and there has to be a whole discipline approach—so that when people do something . . . you can hold them accountable. And that has not been done there.”37
Although it is possible that measures were taken to heighten patient safety each time a medical negligence issue arises, as Supervisor Burke suggests, these measures have simply failed to prevent repeated instances from occurring. This is evidenced by the frequency with which patients have died at doctors’ and nurses’ hands for much of the hospital’s lifetime. Regardless, the most recent limited changes have forced the hospital to close several of its units, sending frustrated community members, who are grateful for nearby medical attention, to protest outside the hospital. According to one activist named Mobley, “We have to stand together to fight this battle. . . .” A community member who has fought for the hospital since its first days, Mobley insisted that, “We have to rise every morning under God’s will…to save Martin Luther King.”38 Lee Russell has joined Mobley’s plight to save the hospital. Russell, who was brought to King/Drew after a shooting and stabbing incident, noted that he would have died had the hospital’s trauma unit been closed when we was injured.39
The supervisors seem to share community members’ struggle, for they are conflicted between recognizing the need for a local hospital in South Los Angeles; yet, they strongly suggest that they are frustrated by the inferior care that King/Drew provides. For example, Yaroslavsky stated that, “ If there is one thing that has been certain at King/Drew over the last few years, if not longer, it’s that aberrations happen too often, and that is obviously of great concern and frustration. I’m really at my wit’s end. . . . It doesn’t seem to stop. It doesn’t seem to end.”40 Gloria Molina is similarly disappointed with herself and fellow supervisors at their failing efforts to solve King/Drew’s problems, stating that, “We [the supervisors] should all be embarrassed, all of us collectively because we have failed the community.”41 King/Drew had failed its local community, particularly the minority communities for which it served as a symbol. The supervisors even acknowledge—somewhat—their role in helping to perpetuate the malpractice that prevented the hospital from healing and serving South Los Angeles’ impoverished community.
Importantly, though, their inability to act responsibly and govern the hospital by establishing and enforcing rules as well as disciplining the medical staff—responsibilities given to them through their role as the hospital’s supervisors—was mediated through an ever pervasive sense of scenic domination: “things are so bad” that supervisor actions were never enough. They “did the best” they could “under the circumstances,” but their actions alone could never be enough. Thus, medical malpractice and disciplinary issues went unreported and undetected. The supervisors failed to solve King/Drew’s problems and create and maintain a safe environment for patients seeking quality healthcare; it was simply, though, not their fault. In short, they did act, yet the scene remained so powerful that their actions were impotent.
Doctors as Agents
The doctors are the second cluster of agents within King/Drew. The supervisors are not solely responsible for allowing doctors to get away with incompetence and malpractice. If not for the doctors’ gross medical mistakes and subsequent malpractice suits, King/Drew’s supervisors would not have had to minimize and hide employee negligence and disciplinary problems. Yes, the supervisors are responsible for governing the hospital, but the doctors are responsible for healing patients and saving their lives, not ignoring patients while their lives and livelihood are taken away. As supervisor Molina stated, “If doctors, nurses, and administrators keep failing us, this hospital is going to sink. . . . That’s my fear.”42 Molina believed that employees need to be held accountable as well, because they currently are not, as is evidenced by the unreported accounts of patient negligence, co-worker assaults, and the hospital’s use of waivers and lies to hide the truth behind patients’ encounters with King/Drew.
The hospital staff failed the community through its acts of staff negligence and disciplinary problems that plagued King/Drew for much of its life. Just after the hospital opened in the early 1970s employees were caught working while inebriated and stealing medication from the pharmacy to sell outside of work. By the end of that decade, King/Drew had earned the nickname, “Killer King,” and was known for its unsanitary conditions, employees who worked under the influence of alcohol or drugs, employee absenteeism, and numerous patient deaths.43
Two doctors exemplify King/Drew’s deadly legacy. The first is Jonathan Heard. Heard, a surgeon at King/Drew, was brought before the supervisory board after he accrued several malpractice suits in 10 years. These charges included administering a police officer a lethal blend of heart medication while treating him for gunshot wounds, perforating a patient’s esophagus during surgery (leading to a serious infection), and billing a man’s insurance company for an appendectomy when in reality Heard had simply stitched through the patient’s intestines leading to an infection that another doctor had to surgically repair.44 According to Heard, these instances are not atypical for doctors. As he declared at one supervisory board meeting, “I want you to find me a surgeon that works in a high-risk field and find one that has not had any type of adverse action against him. . . .”45
The second doctor, Dennis Hooper, was responsible for similar medical malpractice issues during his tenure at King/Drew. A pathologist, Hooper frequently misdiagnosed patients; he often reported that some had cancer when their biopsies were in fact benign, and at other times he failed to identify malignancies. These mistakes led to unnecessary medical procedures and to patient deaths. As one example, Hooper misdiagnosed Johnnie Mae Williams with uterine cancer, which required her to endure an unnecessary radical hysterectomy. Hooper’s colleagues at King/Drew were appalled by his performance. Dr. Timothy Dutra, a fellow pathologist at the hospital, noted Hooper’s disregard for his careless mistakes, stating that, “He would make these casual diagnoses that were wrong and they didn’t seem to bother him.”46
Frustrated by Hooper’s negligence, Dutra and four colleagues wrote to their administrators about Hooper’s fatal errors and malpractice suits. But nothing came of it, perhaps because the administrators say they never received the letter. According to Dutra, “Here you had five pathologists signing a letter listing causes and telling administrators in no uncertain terms that this pathologist has competency problems. . . . And there was no response.”47 So Dutra went above his administrators and began writing first to the hospital’s supervisors and eventually to the South Los Angeles auditors and state medical board. It was county auditors that finally investigated Hooper’s performance at King/Drew, but by the time they recommended disciplinary action, Hooper had already left to work at a San Antonio hospital.48
King/Drew is a teaching hospital affiliated with Charles R. Drew University. As the supervisors failed in their responsibilities to ensure that the hospital fulfills its purpose of healing and serving the community, some doctors associated with the university similarly reject their responsibility to oversee residents, and as such, mistakes have led to patient deaths and injuries.While completing her OB/GYN residency at King/Drew, Dr. Penelope Velasco had three medical malpractice suits brought against her, two of which were related to delivery delays that resulted in physical and mental impairments or death in babies. The third suit was the result of Velasco stitching through a patient’s colon when operating to remove ovarian cysts. The error proved fatal when the patient died 12 days later, after Velasco and her supervising doctors failed to notice the mistake. Like Dr. Heard, Velacso sees such errors as commonplace in her field, stating that, “It’s just the nature of medicine, the nature of life.”49
Additionally, convicted child abusers without the appropriate education have been hired as physicians’ assistants, like Andrew Josiah, who “spent his nights working at King/Drew and his days at the halfway house where he was serving out a sentence for felony child abuse...[after] trying to choke his 12-year-old son.”50 Furthermore, people who failed or dropped out of medical school—and thus did not have medical licenses—were also hired to staff the hospital.51
Nurses as Agents
The hospital’s nurses are the third cluster of agents within King/Drew. Nurses have been known to leave their shifts early, thus abandoning their patients and leaving them without care. They have also been noted to take meals when unauthorized to do so and to turn off patient monitors on their own initiative. In all of these instances, there have been patient deaths. One such instance involved a two-year-old who was on a ventilator. His nurse, without leave, left early for dinner, and the toddler suffered “profound mental retardation” after his breathing tube came loose and none of the other employees checked on him.52 Another case involved a 28-year-old AIDS patient, on whom a nurse was supposed to check. The nurse left before checking in on him that evening at 6 p.m., but falsified his chart to make it seem as though she had visited him at that time; in reality, the patient died at 5 p.m., alone, after his monitors had been turned off earlier.
Furthermore, nurses administered the wrong medicine to patients, including William Watson, who was hospitalized for meningitis. Watson received Gleevec, a chemotherapy drug, when nurses failed to check his chart after a mistake was made in the pharmacy. Watson survived, but his eyes swelled to the size of golf balls over the four days that he was given the drugs. Once nurses discovered the mistake they had the patient sign a waiver, telling him, “We can just forget about it, and squash it like it never happened.” He signed the waiver because he had not known better.53 Other times, nurses failed to provide basic care and assistance to patients. One case is that of Robbie Billbrew, who has hospitalized for her problems in a unit that provided patients with additional nursing attention than regular patients receive. Yet Billbrew received little care from her nurses let alone additional care, leaving her daughters to tend to their mother’s bedsores and clean her breathing tube. “We had to do everything,” recalls Cynthia Millage of the basic care she had to provide her mother.54
As dangerous as the hospital is when its employees are at work, there have been numerous times when doctors and nurses simply fail to show up for their shifts. Entire units—from orthopedic suites to emergency rooms—have temporarily closed as a result and patients are left without medical staff to treat them and are thus forced to travel to another of the county’s hospitals for treatment.55
The Los Angeles Times series provides copious evidence to support the hospital staff’s collective inaction regarding these gross accounts of patient deaths, injuries, and staff inadequacies. Yet the journalists’ act of writing the series ultimately created a scene constituted by a disordered hierarchy and confusion regarding responsibility for patients that perpetuated the staff’s medical malpractice. This scene was powerful, so much so that it prevented the social action required to allow the hospital’s agents to act in a way that would support the hospital’s purpose and also create a new healthy scene marked by quality healthcare. Essentially, the journalists’ act of writing solidified the hierarchical break within the King/Drew hospital by enabling those involved to avoid purifying their evident guilt regarding the hospital’s inability to serve the community because of its gross issues with medical malpractice.
Within King/Drew’s hospital hierarchy, members have positions of superiority and domination beginning at the top with supervisors, followed by the hospital’s doctors, nurses and other staff, then the patients and their families. The people who comprise the more powerful positions in the hierarchy—namely, staff—have responsibilities to other members of the hierarchy and themselves depending upon their position within this medical social structure. King/Drew’s staff had a responsibility to heal and serve the community through quality patient care and ensuring such care through regulations within the hospital. When the staff refused to accept these responsibilities—by not enforcing regulations to curb patient deaths and staff negligence and making numerous significant medical errors resulting in patient deaths—they rejected their positions within the hospital’s hierarchy and a polluted hierarchy only reinforced itself.
When we view this through Burke’s notion of Motivation, we can better understand how the series of articles failed to establish a redemptive cycle. We saw that the journalists’ act was the series of public service stories. The purpose of these stories was to shed light on a rather intractable and deadly problem with King/Drew. The way in which the journalists described the situation (our external analysis) could have, in Burkean terms, constructed a motive for action within those reading the articles. By analyzing the manner in which the journalists described the situation, we can then determine how the journalists named “their structure and outstanding ingredients, and name[d] them in a way that contain[ed] an attitude toward them.”56 Within this attitude lies the motive at the heart of the journalists’ act of writing the stories. However, within their act, the journalists created multiple competing agents (supervisors, doctors, and staff), each of which discursively constructed a powerful scene (our internal analysis), one that eclipsed the act and purpose of the journalists.
Put another way, the journalists’ act of writing was done with the purpose (we assume here) of exposing the negligent acts of King/Drew staff. However, in the act of writing about these acts, the journalists instead created (through their reported descriptions given by the supervisors, doctors, and staff) a disordered scene of such proportions that it was no longer just part of the hospital staff’s (agents) description. Instead, the scene created overpowered the described acts. Thus, we begin the award-winning series with an act-purpose ratio and end it with a scene-act ratio.
Viewed externally, the pentadic elements of the situation showed a domination of acts. The journalists set out to show the problems with King/Drew and detailed dozens of negligent acts that had occurred at the hospital throughout the years. In explaining a stress upon acts, Burke writes that “things are more or less real according as they are more or less energeia [activity] (actu, from which our ‘actuality’ is derived). [F]orm is the actus, the attainment, which realizes the matter.”57 Externally, this domination of acts suggests a philosophical realism influences the apprehension of the situation and subsequent discourse. Realism is the belief “in the real existence of matter as the object of perception (natural realism); also, the view that the physical world has independent reality, and is not ultimately reducible to universal mind or spirit.” Such a motivation stresses “the existence of objects in the external world independently of the way they are subjectively experienced.”58 The journalists put forward a narrative that stressed the heavy reality of the situation, the facts that show the pattern of abuse and neglect. As Brock, Scott, and Chesebro note, “the realist grammar begins with a tribal concept and treats the individual as a participant in substance.”59 In this sense, the hospital agents were envisioned to work together to compound the problem; in this way, they would also, we assume in the eyes of the journalists, accept responsibility to mortify or to be scapegoated.
When one moves from viewing this situation externally to internally, from journalists as agents in the act of writing to an internal understanding of the text they created, one finds a noticeably different construction of events. Instead of having the (external) act of writing with the (external) purpose of exposing the hospital’s sins, the writers constructed too detailed a world, one in which the hospital agents came alive and were allowed to create their own scene in their own words. The acts described above are still the acts of the hospital supervisors and staff. However, when one looks at the series of articles as a single text created by the journalists, examining it internally for pentadic elements, one finds not the act taking dominance, but rather a powerful tripartite agent creating a dominating scene. In short, we move from the act as dominant to a scenic domination at the root of the failure to establish a cycle of order.
The scene is a cacophony of negligence, malpractice, and entrenched systemic failure. Since there are three clusters of agents, each points to the others, and each points to a problem (scene) larger than itself. They construct, and are interpolated into, a scene so dominating, that they could do nothing. Even when specific acts of malpractice and negligence are mentioned in the articles, they fail to provide traction for change. This “scenic collection of acts”60 instead functions as a background of sorts, directing attention away from culpable agents and onto instead a hopeless situation. This scenic domination suggests a philosophical materialism operating throughout the collective stories of the hospital agents. Of materialism, Burke wrote “that metaphysical theory which regards all the facts of the universe as sufficiently explained by the assumption of body or matter, conceived as extended, impenetrable, eternally existent, and susceptible of movement or change of relative position.”61 It is “the theory which regards all the facts of the universe as explainable in terms of matter and motion. . . .”62
Burke suggests that this understanding allows us to view action as reduced to motion when scene dominates. According to Jim A. Kuypers:
In this sense, only the material is significant; that which is observable, touchable, and measurable takes precedence over other concerns. The observable, touchable, and measurable are the assumptions of a positivistic science. This materialistic motive also allows pressure to be placed upon those interpellated within the scene. We are a part of that which is occurring, but we are not necessarily able to remove ourselves from it. The previously described acts emerge out of the scene. Although the realism attached to the acts seem to place principle over material objects, by describing the scene as the dominating genesis, [the hospital staff] allowed for the situation to control the acts.63
There is a certain determinism operating here, a domination of the mind by the scene. Viewed another way, one could construe outside elements as pushing or coercing the hospital agents to act in a particular way. Of note, though, is that even with a scenic domination, an agent could be empowered to act, to initiate a redemptive cycle. This obviously did not happen in the King/Drew situation, neither by the journalist agents nor the hospital staff agents. But why not?
Viewing the redemptive cycle as a form of narrative provides us with insight into the failed King/Drew restoration. Edward C. Appel offers insight into viewing the redemptive cycle as a narrative: “the terms of the guilt-redemption cycle can be viewed or can function as both a nontemporal logic (that is, as a dialectic) and a narrative progression (that is, as a drama), not just as a temporal ‘process’ . . . or temporal sequence. . . .”64 The Pulitzer Prize articles were, at their core, constructed as a narrative, a series that worked to tell the story of King/Drew. Appel suggests that there is “an equivalency” among the terms of the pentad and “the terms implied by the idea of order”; in some senses, they are “interconnecting stages, moments, or concepts.”65 Accordingly, when “viewing the terms of the pentad dialectically the ‘features of action’ may take on any combination; when viewed dramatically, however, ‘they progress from disordered scene to sacrificial act to redeemed purposes and agencies.’”66
Recall, though, that the journalists’ act-purpose ratio gave way to the scene-act ratio contained within the narrative itself. If we view all of this externally, we could well see a grammar of interconnected pentadic terms for the situation, something that produces a static view. However, if we look at the situation internally, then we can see the interconnected pentadic terms as a drama, one in which the various elements could be drawn out “into a temporal succession.”67 From this point of view, a disordered hierarchy is presented as the (1) scene; this scene required (2) agents to offer sacrifice/purification in the form of an act, which, in turn, would lead to a new order with (3) agencies and purposes commensurate to this new order. This dramatistic cycle, however, rises or falls on the willingness or ability of an agent to assume mortification or scapegoating; either way, it necessitates an agent who would offer “redemption through his acts. . . .”68
Such was not the case with King/Drew. The journalists simply failed to provide a way to challenge the powerful scene that they had created. As J. Clarke Rountree, III has written, “relations among grammatical terms function as rhetorical constraints that do not dictate action, but shape the interpretation of action. By extension, these constraints function when one attempts to account for any sort of action, whether undertaken by one's self or another.”69 In a sense, the trouble was institutional, thus no single agent was powerful enough to challenge the problem—one scapegoat or one act of mortification was insufficient. The journalists presented a domination of acts—from the act of writing, the journalists created a series of acts within their text. However, these acts were so well described that they created a scenic oppression; moreover, the acts were allowed to be explained by well described agents (supervisors, doctors, and staff) in such a manner that “act as dominating” gave way to “scene as dominating”: human action was replaced by human motion. The agents (supervisors, doctors, staff) are prisoners of the scene. Because of this, the cycle of redemption simply stalled. No moral agent stepped up to act after the series of articles. No redemption: the agencies and purposes were never truly presented as open to transformation. Instead, there was simply a non-act, the allowing of things to remain the same. Guilt and pollution remained, and the scene continued to dominate. The agents and their purposes continued down the same path.
Viewed in this manner, the staff simply failed to purify at a level appropriate to its guilt. Although they acknowledge disappointment and embarrassment in the current supervisory system, as well as the consequential patient deaths their medical mistakes accrued, they did not purify at a level appropriate to their rejection, guilt, or to the consequences that their inaction has created for the hospital. Simply stating embarrassment and frustration (at the scene) cannot possibly purify the supervisors because these purification attempts are meager mortification compared to the hospital’s accumulating number of patient deaths and medical malpractice fees.
Years after the 2004 LA Times series ran, King/Drew continued to crumble. The hospital lost its accreditation in 2005, and in 2006, the hospital lost $200 million of its total $380 million budget after failing to pass a federal Medicaid and Medicare inspection in 9 of the 23 examined areas.70 With such a devastating loss, the hospital’s supervisory board was left with difficult decisions. How many other units would need to be closed? And should King/Drew’s managerial duties be transferred to a credible hospital, such as one of the UCLA Medical Centers, which would provide South Los Angeles’ residents with the services that King/Drew would no longer have? Despite the dangerous environment and incidents that led to the hospital’s failed inspection and funding cuts, community members were angered at the prospect of once again having limited access to healthcare, despite its inadequacy. Limited care, even very poor, seemed better than no care at all.
One community member angered by this situation was Mollie Bell. Bell, who helped fight to promote the need for quality local healthcare in South Los Angeles during the Watts riots, saw the potential hospital closure as a return to the 1960s, when residents—many of whom did not have personal transportation—had to travel to other communities to seek medical treatment.71 Others, including the Los Angeles County Medical Association’s (LACMA) and California Medical Association’s (CMA) presidents—Dr. Ralph DiLibero and Dr. Michael Sexton, respectively—shared Bell’s distress. Both spoke about the detrimental effect this limited access to medical care would cause South Los Angeles’ residents and made statements supporting the hospital’s supervisory committee in its efforts to salvage the hospital’s services. In a press release issued by the CMA, DiLibero stated that “LACMA thanks the…County Board of Supervisors for their continued reasoned and deliberate positive response to this healthcare delivery crisis…and all the efforts that have been put forth to correct the mistakes of the past and to create an effective, safe, and perpetual healthcare system.”72
We do not feel, however, that the Board of Supervisors was responding appropriately to solve the hospital’s history of patient negligence and redeem its reputation; this is evidenced by the hospital’s failed federal inspection and loss of over half of its budget. This ineffective leadership would continue, despite the hospital’s partnership with Harbor-UCLA Medical Center after the 2006 funding cut. By 2007, still more patients had died from nursing negligence, one of whom collapsed in the emergency room and writhed in pain as employees ignored her. During this same year, the partnered hospital failed yet another federal inspection, forcing it to close in spite of residents’ and hospital leaders’ arguments to keep it open.73
Without purification, there was no redemption, and a broken hierarchy persisted. Instead of guilt, purification, and redemption, denial, obfuscation, and rationalization was allowed to thrive in the scene the reporters crafted. We believe a contributing factor in King/Drew’s demise was the inability of its supervisors and doctors to acknowledge their collective guilt; they simply failed to try to purify in ways that were appropriate to the magnitude of their hierarchical rejection. This lack of fitting purification is why the hospital’s efforts to change its policies and redeem its reputation failed. Without the right form of purification, redemption could not be achieved, thus allowing the dramatic cycle of destruction to continue within the King/Drew hospital. Regardless of how many consultant teams were hired and units were closed, the hospital continued to provide inadequate healthcare and to steal its patients’ lives and livelihood while those at the top of the hospital’s hierarchy failed both to accept their positions and responsibilities and to appropriately purify to achieve redemption and thus end the cycle of destruction.
Undoubtedly, the Pulitzer Prize-winning series on King/Drew makes for heart-wrenching and intense reading; these are very good stories. However, the stories’ scenic focus allowed for those responsible for the chaos to elude responsibility by simply blending into the scene, pointing to the acts of others, and continuing acts of medical malpractice. The reporters created a world in which the hospital’s agents were subordinated to the scene, and in such a state, those in King/Drew need not, or could not, take on the necessary guilt, since the guilt was a systemic problem 32 years in the making. It is possible that purification was unattainable after 32 years of accumulated medical malpractice fees, patient deaths, and staff negligence because the magnitude of purification must match the magnitude of guilt that the agents have acquired. Those decades destroyed the hierarchical relationships that cemented the hospital’s structure. King/Drew had begun to crumble long before the Los Angeles Times published its series, and it is possible that too much time and too many failed attempts at purification prevented the hospital from re-establishing its integrity and strength. Sometimes a building simply cannot be refurbished, and it must be torn down.
Burke believed that drama was everywhere and once wrote that “the drama . . . may be studied as a ‘perfect mechanism’ composed of parts moving in a mutual adjustment to one another like clockwork.”74 But King/Drew was imperfect. The drama only works when all of its parts of guilt, purification, and redemption are present and functioning once a hierarchical rejection has wrenched this mechanism. Without just one of these elements, the drama will continue to cycle until its interior structure crumbles, as was the result of King/Drew.
By first focusing on the journalists’ actions in writing the series and then conducting a similar analysis of the dramatic world that they created within King/Drew, we were able to explore how King/Drew’s scene allowed for persistent medical malpractice actions that prevented the hospital from fulfilling its purpose of healing and serving the community. Finally, by uniting both pentadic analyses, we were able to identify the missing piece to resolution despite many attempts to solve the hospital’s problems.
Because the dramatistic application revealed an integral part to the hospital’s failure after numerous employees’ and supervisors’ rejection of their hierarchical position, it might be useful to apply the same perspective to other Pulitzer Prize-winning public service series to determine if cyclical series of events are perpetuated by the absence of a similar dramatistic element. Or the reverse, one could ask if prize-winning stories which were followed with some form of action allowed for a dramatistic cycle to properly function. Was the transgressed hierarchy identified, guilt assumed, and redemption achieved? However, since only one such series was examined in this case, similar studies would have to be conducted to determine a definite correlation between Pulitzer-winning series and missing dramatistic elements.
1. “Public Service,” Pulitzer.org: http://www.pulitzer.org/bycat/Public-Service (accessed February 8, 2010).
2. “Public Service,” 319.
3. Brian L. Ott and Eric Aoki, “The Politics of Negotiating Public Tragedy: Media Framing of the Matthew Shepard Murder,” Rhetoric and Public Affairs 5, no. 3 (2002).
4. Daron Williams and Jim A. Kuypers, “Athlete as Agency: Motive in the Rhetoric of NASCAR,” Kenneth Burke Journal 6, no. 1 (Fall 2009).
5. Kenneth Burke, “Dramatism,” International Encyclopedia of the Social Sciences, vol. III., David L. Sills, ed. (New York, Macmillan/The Free Press, 1968): 445.
6. Bernard Brock, Robert L. Scott, and James Chesebro, “Rhetorical Criticism: A Burkeian Approach Revisited,” Methods of Rhetorical Criticism: A Twentieth-Century Perspective 3rd Ed/ (Detroit, Wayne State University Press, 1990): 185.
7. Kenneth Burke, A Rhetoric of Motives (Berkeley, University of California Press, 1950): 141.
8. C. Allen Carter, Kenneth Burke and the Scapegoat Process, (Norman: OK, University of Oklahoma Press, 1996), 10.
9. Carter, 10.
10. Brock, Scott, and Chesebro, 185.
11. Edward C. Appel, “Implications and Importance of the Negative in Burke’s Dramatistic Philosophy of Language,” Communication Quarterly 41, no. 1 (Winter 1993): 60.
12. Brock, Scott, and Chesebro, 187.
13. Kenneth Burke, The Rhetoric of Religion: Studies in Logology (Berkeley, University of California Press, 1970), 231.
14. Burke, “Dramatism,” 450.
15. Kenneth Burke, Permanence and Change, 3rd ed. (Berkeley; University of California Press, 1984), 284.
16. Rise Jane Samra, “Guilt, Purification, and Redemption,” The American Communication Journal 1, no. 3 (May 1998): 2, http://acjournal.org/holdings/vol1/iss3/burke/samra.html (accessed October 22, 2009).
17. Burke, “Dramatism,” 449.
18. James F. Klumpp, “Burkean Social Hierarchy and the Ironic Investment of Martin Luther King,” in Kenneth Burke and the 21st Century, Bernard L. Brock, ed. (Albany, State University of New York Press, 1999): 237.
19. Burke, A Rhetoric of Motives, 141.
20. Floyd Douglass Anderson, Andrew King, and Kevin McClure, “Kenneth Burke’s Dramatic Form Criticism,” in Rhetorical Criticism: Perspectives in Action, ed. Jim A. Kuypers (Lanham, MD: Lexington Books, 2009),146.
21. Los Angeles Almanac, online version at http://www.laalmanac.com/LA/la11c.htm
22. “Editorial: Fulfilling the Wrong Dream,” Los Angeles Times (December 12, 2004): 1, http://www.pulitzer.org/archives/6951 (accessed October 24, 2009).
23. “Brief History of King/Drew Medical Center,” (July 12, 2004): 1, http://126.96.36.199/message_ceo.asp (accessed November 22, 2009).
24. “Brief History of King/Drew Medical Center,” 2.
25. Mitchell Landsberg, “Why Supervisors Let Deadly Problems Slide (part 1),” Los Angeles Times (December 9, 2004): 1, http://www.pulitzer.org/archives/6948 (accessed October 24, 2009).
26. Charles Ornstein and Tracy Weber, “For Days, Potent Drug Given to Wrong King/Drew Patient,” Los Angeles Times (February 26, 2004): 1, http://www.pulitzer.org/archives/6953 (accessed October 24, 2009).
27. Landsberg, “Why Supervisors Let Deadly Problems Slide (part 1),” 2
28. Steve Hymon, Charles Ornstein, and Tracy Weber, “Massive Overhaul of Ailing Hospital Urged,” Los Angeles Times (December 23, 2004): 4, http://www.pulitzer.org/archives/6952 (accessed October 24, 2009).
29. Mitchell Landsberg, “Why Supervisors Let Deadly Problems Slide (part 1),” 2.
30. Landsberg, 2.
31. Landsberg, 2.
32. Mitchell Landsberg, Charles Ornstein, and Tracy Weber, “Deadly Errors and Politics Betray a Hospital’s Promise,” Los Angeles Times (December 5, 2004), 5.
33. Mitchell Landsberg, “Why Supervisors Let Deadly Problems Slide (part 1),” 1.
34. Steve Hymon, Charles Ornstein, and Tracy Weber, “Massive Overhaul of Ailing Hospital Urged,” 2.
35. Charles Ornstein and Tracy Weber, “For Days, Potent Drug Given to Wrong King/Drew Patient,” 2.
36. Landsberg, Ornstein, and Weber, 6.
37. Ornstein and Weber, “For Days,” 2.
38. Landsberg, Ornstein, and Weber, 3.
39. Landsberg, Ornstein, and Weber, 4.
40. Charles Ornstein, “Clamp is Left in King/Drew Patient,” Los Angeles Times (July 13, 2004): 1,
http://www.pulitzer.org/archives/6954 (accessed October 24, 2009).
41. Mitchell Landsberg, “Why Supervisors Let Deadly Problems Slide (part 1),” 2.
42. Charles Ornstein and Tracy Weber, “For Days, Potent Drug Given to Wrong King/Drew Patient,” 3.
43. Mitchell Landsberg, “Why Supervisors Let Deadly Problems Slide (part 1),” 3.
44. Ornstein and Weber, “Other Doctors Faulted,” 1.
45. Ornstein and Weber, “Other Doctors Faulted,” 1.
46. Tracy Weber and Charles Ornstein, “One Doctor’s Long Trail of Dangerous Mistakes (Part 3),” Los Angeles Times (December 7, 2004): 5, http://www.pulitzer.org/archives/6941 (accessed October 24, 2009).
47. Weber and Ornstein, “One Doctor’s Long Trail,” 2.
48. Weber and Ornstein, “One Doctor’s Long Trail,” 3.
49. Charles Ornstein and Tracy Weber, “How Whole Departments Fail a Hospital’s Patients (Part 4),” Los Angeles Times (December 8, 2004): 4, http://www.pulitzer.org/archives/6943 (accessed October 24, 2009).
50. Charles Ornstein and Tracy Weber, “How Whole Departments Fail a Hospital’s Patients (Part 4),” 3.
51. Ornstein and Weber, “How Whole Departments,” 3.
52. Steve Hymon, “The Lost and Bereaved: a Damaged Boy,” Los Angeles Times (December 8, 2004): 1, http://www.pulitzer.org/archives/6944 (accessed October 24, 2009).
53. Charles Ornstein and Tracy Weber, “For Days, Potent Drug Given to Wrong King/Drew Patient,” 2.
54. Ornstein and Weber, “For Days, Potent Drug,” 6.
55. “Editorial: Perilous Chairs,” Los Angeles Times (December 7, 2004): 1,
http://www.pulitzer.org/archives/6950 (accessed October 24, 2009).
56. Burke, The Philosophy of Literary Form, 2nd ed. (Baton Rouge: Louisiana State University Press, 1967), 1. See pages 6, 298-304, as well. Andrew King provides a detailed discussion of Burke’s notion of motive in, “Motive,” The American Communication Journal 1, no.3 (1998), (http://www.americancomm.org/~aca/acj/acj.html). For additional insight, see, J. Clarke Rountree, III, “Coming to Terms with Kenneth Burke’s Pentad,” The American Communication Journal 1, no.3 (1998), http://www.americancomm.org/~aca/acj/acj.html.
57. Kenneth Burke, A Grammar of Motives (Berkeley; Los Angeles; London: University of California Press, 1969), 227.
58. “Realism,” Oxford English Dictionary, 2nd Edition (OED2). On-Line version.
59. Bernard L. Brock, Robert L. Scott, and James W. Chesebro, eds., Methods of Rhetorical Criticism: A Twentieth-Century Perspective, 3rd ed. (Detroit: Wayne State University Press, 1990), 188.
60. Jim A. Kuypers, “From Science, Moral-Poetics: Dr. James Dobson's Response to the Fetal Tissue Research Initiative,” Quarterly Journal of Speech 86, no. 2 (2000): 154.
61. Burke, Grammar of Motives, 131.
62. Burke, Grammar of Motives, 131.
63. Kuypers, 154-155.
64. Edward C. Appel, “Position Paper: Using Kenneth Burke in Rhetorical Criticism.” Paper presented at the Kenneth Burke Society Conference, New Harmony, Indiana, 1990, p.4.
65. Appel 5.
66. Kuypers, quoting Appel 5.
67. Burke, Grammar of Motives, 264; see also 15-16.
68. Kuypers. For a discussion of the linkage between the pentadic terms and the cycle of order see: Kenneth Burke, The Rhetoric of Religion,180-189.
70. Sonya Geis, “South-Central L.A. Hospital in Critical Condition,” Washington Post, (October 4, 2006): 1, http://www.washingtonpost.com/wp-dyn/content/article/2006/10/03/ (accessed November 23, 2009).
71. Geis, “South-Central L.A. Hospital in Critical Condition,” 1.
72. Rebekah Alperin and Karen Nikos. “LACMA and CMA Statements on King/Drew Medical Center and the Threat to L.A. County Health Care,” California Medical Association, (October 2, 2006): 1, http://www.cmanet.org/publicdoc (accessed November 23, 2009).
73. Garrett Therolf, Mary Engel, and Jean-Paul Renaud, “County Medical Crisis Deepens,” Los Angeles Times (April 11, 2008): 3, http://www.latimes.com/news/local/la-me-chernofresigns (accessed November 23, 2009).
74. Burke, “Dramatism,” 449.
* Dr. Jim A. Kuypers (Ph.D., LSU) Department of Communication at Virginia Polytechnical Institute and State University. Ashley Gellert (M.A. Virginia Polytechnical Institute and State University), Department of Communication. They can be reached at firstname.lastname@example.org and email@example.com
"The Story of King/Drew Hospital: Guilt and Deferred Purification" by Jim A. Kuypers and Ashley Gellert is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.