Living ethically within health care organizations
Objectives
• List several areas of health care addressed by organization ethics.
• Define the term mission statement and the role of a mission statement in an organization.
• Describe several ethical principles that are useful in the analysis of organization ethics problems.
• Identify three rights of professional employees in health care organizations.
• Name some business and management challenges in organizations that warrant ethical reflection.
New terms and ideas you will encounter in this chapter
organization ethics
mission statement
policy
conflict of interest
stakeholders
cost effectiveness
organization ethics committee
principle of participation
principle of efficiency
Topics in this chapter introduced in earlier chapters
| Topic | Introduced in chapter |
| Values and duties | 1 |
| Courage | 1 |
| Moral agent | 3 |
| Moral distress | 3 |
| Ethical dilemma | 3 |
| Locus of authority problem | 3 |
| Virtue | 4 |
| Prima facie and absolute duties | 4 |
| Utilitarian theory | 4 |
| Principles approach | 4 |
| Beneficence | 4 |
| Nonmaleficence | 4 |
| Justice | 4 |
| Autonomy | 4 |
| The six-step process of ethical decision making | 5 |
| Aspirations | 7 |
Introduction
So far, we have focused on the individuals and the ethical challenges they face in their professional role and work environment. In this chapter, we turn more directly to the organizational dimensions of health care. Another critical area of ethical reflection in health care is organization ethics. Organization ethics pays attention to the values, character traits, rights, and duties expressed in:
Organization ethics cuts a wide swath across your professional life. The field addresses issues in organizational structures that deliver health care, those that regulate health professionals or health care practices, professional associations, businesses that provide health care equipment or material for procedures, pharmaceutical companies, and those involved in remuneration for professional services. Subsets of organization ethics are business ethics, management ethics, administrative ethics, and legislative ethics, to name some. Each addresses the conditions under which an organization’s and society’s moral expectations can be reconciled. They focus on the larger societal and bureaucratic organization of modern health care; therefore, their goals are not limited solely to the ethical goals of individual health professionals. Institutional policies and actions affect patient care, so a lens must be placed on health care organizations and professionals. For instance, a business goal of increasing the profit margin each year is legitimate for a business enterprise. Business ethics addresses the conditions required for that profit margin to be gained, with adherence to high ethical standards set by its consumers of their products or services, society, and the organizations themselves. Robert Hall1 notes that health care organizations have ethical problems that in many ways are similar to good business management anywhere, but because of the special place the professions have in society, these organizational structures must be styled to fit the type of role its employees and “clients” play. As a participant in various health care organizations, your challenge is to assess whether the rights, values, and duties by which they abide affect your ability to offer a caring response to patients when measured against the standard of your professional values and duties. To illustrate one version of how the ethical challenges of working within an organization affects health professionals, consider the following story.
The Story of Simon Kapinsky and the Subcommittee to Implement a Green Health Plan
The Chief Executive Officer (CEO) of StarServices, Inc, a for-profit major health plan, has asked Simon Kapinsky, a senior member of the professional staff in one of the plan’s units, to chair the ethics subcommittee of the health plan’s greening advisory council. The advisory council recently was formed to set new policy and practices for StarServices, Inc, to operate as a “green health plan” in regard to the services it offers. On review of the material from the CEO, Simon learns that the Board of Trustees of the health plan signed a contract 2 years ago to build or remodel all of its treatment (not research) units according to concepts of ecologic architectural design. Simon is aware that the flagship hospital in the health plan (where he is employed) already has undergone major renovation, but he was not fully aware of the scope of the project. In the proposal, the greening of the health plan is being financed one fourth by StarServices, Inc, one half by bonds in the city where the major institutions of the health plan are located, and one fourth by Green International, a private architectural firm whose purpose is to showcase ecologic architecture in public buildings. Green International claims that the new health plan structures will become the showcase for eco-friendly medical facilities in the next 50 years. The estimated overall cost is $36 million, but Green International emphasizes that much of that cost will be recovered by offsetting operating costs and also by the amount of business this eco-friendly model project will generate. When Simon returns the material to the CEO, the latter emphasizes, “With the flagship hospital in the health plan already renovated, StarServices, Inc, is positioned to move ahead substantially toward its strategic goal of becoming the greenest health plan in the world. Welcome to the leadership team, Simon! Now the next step is to rescale ours services according to the overall ecologic impact of the range of clinical services it offers.”
Simon is not exactly thrilled at the prospect of serving on this subcommittee, but with his CEO appointing him to the post, he also does not feel that he has any good alternative but to accept. That night, he goes home and discusses it with his partner, who is also a health professional. Over dinner, they come up with some questions Simon will urge the subcommittee to raise about the project. They agree that as concerned and ethically informed professional leaders, there is more to take into account than to jump on the bandwagon of excitement about being the “greenest health plan in America,” as laudable as that goal is.
Some of the questions they come up with include:
• Should a health care plan choose patient services on the basis of ecologic impact?
• Knowing that the decision apparently has been made to take this approach,
• Should some types of patients be excluded from this health plan, or is it more ethical to decrease the therapies that have the biggest ecologic impact and compromise efficiency?
At the first meeting of the ethics subcommittee, Simon is gratified to learn that all of them have some of the same questions and some other concerns about why the patient services angle is the focus of the administration. Most are not convinced that every stone has been turned to look for cost-saving and ecologically responsible changes in the way things are done at the various institutions of the health plan to warrant this jump to a cut or cutback in patient services.
At the end of the second meeting, the subcommittee is confident that their questions raise serious enough concerns that they should be submitted to the CEO and advisory council for further discussion before the subcommittee continues. Simon makes this recommendation to the chair of the advisory council and sends a copy of the minutes to the chair and CEO. He is surprised when at the next meeting of the full council the chairperson does not mention it.
Several weeks more go by and the subcommittee members are wondering why they have not heard from the CEO or advisory council chairperson. Finally, Simon calls the CEO, who says, “I have just been writing a letter to you and the subcommittee thanking you for your service. We have hired a management firm to help us determine where the highest costs are being incurred for patient services, and they have agreed to factor in some data units about projected ecologic costs of various procedures. We felt we had to move ahead to keep the project on schedule.” Simon responds with a stunned silence. The CEO, noting this continues, “Don’t get me wrong. We really are appreciative of your hard work, but, frankly, delaying some management decisions were judged to be too costly. I think in time any ethical problems will iron themselves out.”
This is the first time in all his years of professional service that Simon feels betrayed. He can hardly believe that no steps will be taken to consider their concerns or that, at the very least, he was not invited into any discussion that may have occurred. As he walks back to his department, he begins to believe that the ethically right thing is not being done and wonders what he should recommend to the subcommittee in the way of a response.
Reflection
What do you think are the major ethical challenges the subcommittee is facing in this situation? What challenges do the CEO and trustees face? Are there serious differences in priorities and perspectives between the two groups? Are there areas of mutual concern and overlap in their priorities?
The goal: a caring response
Just as health professionals are moral agents whose ethical judgment should be guided by the goal of a caring response in the health professional and patient encounter, so must this goal govern in situations that involve the organizations of health care. The “character traits,” needs, and rights of the organization must be taken deeply into the equation as a part of the analysis. The voice of the organization is expressed through the administrators and others who look out for the administrative interests of the organization (i.e., the CEO and chief financial officer [CFO], trustees, and in privately owned institutions, the stockholders). You can correctly think of them as the moral agents charged with protecting the values of the organization. Well-working organizations such as StarServices, Inc, often strive to also include mechanisms for involving employees or consumers of their products or services, all moral agents, with the latter reflecting community concerns. Each interest group can be seen as a moral agent.
The six-step process in organizational matters
Given that there are several moral agents, you will gain some important insights by walking with Simon and the subcommittee through their experience, with the six-step process of ethical decision making as a framework.
Step 1: gather relevant information
Where can Simon’s subcommittee go to address the apparently dismissive conduct of the administration? How can they find out exactly why it was dismissed? We propose that it will require Simon and the subcommittee to gather data in different places than if the issue pertained to their search for a caring response between themselves and their patients. As noted at the outset of this chapter, the values and priorities of organizations can be found in their mission statements, policies and administrative practices, and business approaches.
Mission statements as relevant information
A mission statement is an organization’s brief description of its ideals and aspirations. Because a mission statement is stated in general terms, the employee can tend to ignore it completely when accepting employment. But it is from these values and ideals that goals, behavioral objectives, and expectations of all users (e.g., patients and all employees) are derived. Sometimes the values of the entity are reflective of religious assumptions. In the United States, many hospitals and schools are owned and operated by religious groups, a situation visitors to other parts of the world may not see. Such an organization makes reference in its mission statement to its understanding of the relationship of humans to God and each other and to the way in which the organization views itself as participating in the larger cosmic and social scheme of things. In contrast, the U.S. Veterans Administration health care plan is an example of a government owned and operated system, now partnering with various private companies for goods and services. One expects its mission statement to read quite differently from that of a religiously based nonprofit health care organization. Box 8-1 contains an example of a simple, straightforward mission statement.
Reflection
1. What does this mission statement tell you about the nature of this institution?
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2. Does this statement say anything that would support Simon and the ethics subcommittee regarding arrangements that might compromise the primacy of high-quality patient care in the StarServices, Inc, health plan?
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Because mission statements become the basis for more specific policies and expectations, it is prudent and responsible to check the mission statement with as much care as possible before becoming part of an organization. This checkpoint should enable you to avoid moral distress or ethical dilemmas further into your affiliation with this body and its policies and practices if you find you do not subscribe to the overall nature of the organization’s mission.
Summary
Like codes and oaths for health professionals, mission statements are organizations’ public statements designed to declare to all the type of organization it is, including its core ethical values and ideals.
Policies and administrative practices as information
A policy is a statement designed to establish formal and informal guidelines for practice within an organization. Obviously, policies should be consistent with the values of the organization. They also should be specific expressions of how the ideals in the mission statement can be carried out by the people in the organization and those the organization hopes to attract or serve. If policies are to be followed, they must also be clear, practical, flexible, and consistent with the values of the people or groups to whom they apply.
Currently, policies in health care reflect both traditional health care ethics and business ethics. One group whose mission was to deliver high-quality patient care once commented, “No money, no mission.” This is probably the perspective from which the CEO of StarServices, Inc, was responding to Simon’s query about the approach the organization was taking to meet their goal of going green. The goals of the organization often are not fully met simply by focusing on the model of a single patient and health professional. As you can imagine, the picture is not always rosy because an organization’s policy may come directly into conflict with professional ethics standards. In fact, it is often at the level of policy that goals for individual patients’ well-being or justice among groups come into direct conflict with business interests. Recently, one of the authors conducted a workshop in a private health care facility that had adopted a “no AIDS patients” policy because of the high costs of services for many such patients. The health professionals were distressed because the facility was in the process of building a new multimillion dollar reception area and surrounding gardens with the hope of its beauty being the draw to “beat out the competition.” This decision by the trustees of the facility was interpreted by the professionals as being a triumph of profits over patients, and still they agreed that the patient load was down because of increased competition in their geographic area.
Summary
Few health professionals today are in situations where they can ignore organization policies. Still, professional values must guide their own decisions.
Related posts:
Surviving student life ethically
Ethics theories and approaches: conceptual tools for ethical decision making
Communication and information sharing
The ethical goal of professional practice: a caring response
Professionals as good citizens: responsibility and opportunity
Ethical issues in end-of-life care
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