Case Management Insider

Solution: Committees on organizational ethics

By Toni Cesta, PhD., RN, FAAN
Senior Vice President
Lutheran Medical Center
Brooklyn, NY

One solution to perennial problems such as ethics issues might be the formation of an organizational ethics committee. Different from a clinical ethics committee, an organizational ethics committee deals with organizational dilemmas that should be solved in a formalized manner. (For examples of common organizational ethics issues, see, below.)

Organizational Ethics Issues Commonly Faced by Case Managers

  • Resolving care-related conflicts
  • Preventing delays in treatment
  • Increasing and facilitating access to care
  • Brokering services within and outside the healthcare organization
  • Obtaining authorizations for treatments from managed care organizations
  • Advocating for patients while working with managed care organizations

An organizational ethics committee can be a sub-committee of the clinical ethics committee, but its membership might be somewhat different. Because the committee is dealing with issues that typically involve financial and insurance issues, the membership must be broader than what one would typically see on an ethics committee that deals solely with clinical issues. Examples of organizational ethics committee membership include:

  • finance/billing;
  • managed care contracting;
  • physician;
  • case management;
  • social work;
  • nursing;
  • administration;
  • legal department;
  • patient relations.

The chair of the committee also should be a standing member of the ethics committee and can report the activities of the organizational ethics committee to the clinical ethics committee. Ethics consults can be called in the same way that clinical ethics consults are called. Members of the committee can be on-call on a rotational basis, and they can take calls for emergent organizational ethical issues as they arise. Most of the issues of an organizational ethics committee can be dealt with via telephone, which helps to facilitate the process.

Case managers can help to facilitate ethics consults in their role as patient advocates in two important ways:

  1. They can ensure that ethics consults are called when they need to be called.
  2. They can ensure that their patients' interests are fully represented and protected in these consults.

Case managers must adjust their ethical self-understanding to fit the managed care environment in which they practice. Like the traditional physician/patient relationship, the traditional nurse/patient and social worker/patient relationship is transformed once cost containment becomes a pressing issue. Under managed care, nurses — and case managers in particular — have conflicting loyalties and obligations. They have obligations to their patients and to the organizations for which they work. Balancing these obligations in an ethically appropriate manner requires that they stop thinking in terms of maximizing the interests of their patients, but rather find the balance between conflicting responsibilities. Ultimately, the case manager must determine what is in the best interest of the patient and the organization, which is a difficult place to be, at best.

An organizational ethics committee provides the structure for another ethical term, shared decision-making. It provides the framework for a process in which multiple parties with various points of view participate in a process that brings them to a conclusion that weighs multiple variables. As far as case management ethical dilemmas, an ethics committee can take the burden off the director of case management when he or she is faced with a question that does not have a clear answer.

There are at least four elements which exist in organizations that make ethical behavior conducive within that organization. The four elements necessary to quantify an organization's ethics are:

  • written code of ethics and standards;
  • ethics training for executives, managers, and employees;
  • availability for advice on ethical situations;
  • systems for confidential reporting.

Good leaders strive to create a better and more ethical organization. An organization with an organizational ethics committee is providing a venue to which case managers and others can take their ethcial dilemmas. Restoring an ethical climate in an organization is critical, as it is a key component in solving the many organizational and ethical problems facing healthcare today!