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As market forces continue to squeeze health care resources, it will become more important than ever for hospitals to expand their concept of "medical ethics" to include more than just individual patient care issues, many experts say. Health systems must be prepared to explicitly examine their mission as health care providers and make hard choices about how administrative, business, and policy decisions will make that mission a reality.
"We have a situation that health care is carried out in the moral framework of the medical profession. At the same time, it has to be carried out in an economic framework that is shaped by the market," says Ann Neale, PhD, senior research scholar in the Center for Clinical Bioethics at Georgetown University Medical Center in Washington, DC. "That is inherently tension-filled because the professional values are quality, compassion, access, and service. Market values — if you are talking about a free-market economy — are productivity, efficiency, profits — or, if we are nonprofit — profit margins."
Too many health care administrators want to leave the examination of "ethics" up to the designated ethics committees debating individual patient care decisions such as end-of-life care and informed consent, and consider business and administrative decisions separately, Neale says. But, in order for clinical ethics committees to continue to function, they must have some sense of the goals and values of the organization for which they work.
"Organizational ethics greatly impact the clinical," she says. "Morally significant ethical decisions in many ways define the possibility of acting with integrity at the level of patient care." The hospital’s hiring practices are a good example, she explains.
"Do we hire enough qualified, competent caregivers?" she asks. "If we don’t, then care is not going to be of good quality. Decisions about staffing ultimately reflect budget constraints and resource allocation. All of these organizational decisions ultimately affect the possibility of acting with integrity at an individual patient level."
And, as important as resource allocation and hiring practices are, they are just a tiny fraction of the issues that hospitals need to place under the umbrella heading of "organizational ethics" considerations, she adds.
"There’s a lot of talk about organizational ethics in health care, but a lot of confusion about what that term means," Neale says. "I think you can distinguish it by saying clinical ethics are involved with decisions about direct patient care, and with organizational ethics, you are dealing with issues of moral significance that occur in health care organizations that do not pertain directly to patient care. It has different subject matter and different primary decision makers."
For hospitals and health systems beginning to consider organizational ethics, the starting point is to define the organization’s "core values" and what it sees as its mission in the community, says Carolyn Ells, RRT, PhD, assistant professor of bioethics at Dalhousie University in Halifax, Nova Scotia, and coordinator of the Department of Bioethics’ Hospital Collaboration. "Defining the core values — that’s the right place to start, but usually we don’t have the luxury of starting there," she notes. "Organizations often have identified values and value statements, but they may not be the values that are actually driving the organization."
Hospital executives and boards of trustees must be willing to examine their strategic plans, budgets, and current organizational structure and decide whether they reflect the goals contained in their mission statements or corporate codes of ethics, say both Ells and Neale.
To put it bluntly, Neale says, the budget should be viewed as the organization’s real "pre-eminent moral statement." "Let’s say as an individual, I keep talking about my concern for the environment, the poor, educationally deprived children," she explains. "But, what do I do with my life? Where do I live? Where do I spend money? Where do I shop, and with whom do I associate? Those are the decisions that really tell you what my values are. I don’t mean that ethically you have to go live in the ghetto and teach in underprivileged schools. But, money talks."
For hospital executives unused to dealing with concepts of ethical frameworks and translating values into practice, this may seem overwhelming, notes Ells. Ells is coordinating a project between the Department of Bioethics and Health Law Institute at Dalhousie and three Halifax-area hospitals — IWK Grace Health Centre, Nova Scotia Hospital, and the Queen Elizabeth II Health Science Centre. The hospitals are receiving ongoing consultation in legal and ethical issues in health care organization and administration, while the academic institutions are researching how organizational ethics theory can best be applied in practice.
To determine where the hospitals should start in terms of ethical organizing, Ells and her colleagues performed a needs assessment, she says. They surveyed almost everyone in the hospitals: clinicians, administrators, ethics committee members, and other staff members to find out what ethical issues they felt were pressing.
The results were telling. "We surveyed a broad section of people, and almost universally, they were more concerned with institutional issues than with patient care [and] ethical issues," she says. "People were interested in organizational issues: communication, how risks are dealt with, how mistakes are dealt with. And there was a lot of interest in the policy process; how policies were made and implemented."
She was able to use the responses in the needs assessment to begin planning activities to help the hospital decision makers begin to examine the organization’s ethics, she says. "Right now, we are in the middle of a six-month series of ethics education with the hospital board and senior executives," she illustrates. Of the three hospitals, two recently merged and those executives have been particularly interested in the project. "The first thing they wanted to address was the issue of ethical problem solving, and they wanted to talk about allocation of resources," she says. "And, we are beginning to talk about ethical policy-making."
Some hospital clinical ethics committees have attempted to "expand" the scope of their work into organizational ethics, notes Neale. But without support from senior management, they are not likely to be successful. "There can be very explicit resistance to dealing with organizational ethical issues," she says. "As ethics committees run into the impacts of these blocks of market and resource constraints, they begin to think, Maybe we should expand our agenda.’ And, in a lot of cases, they are told, No, you handle the patient care issues, we’ll handle the staffing and resource issues.’"
The question of who should be "in charge" of organizational ethics is still up for debate. Can clinical ethics committees expand their mandate and cover these issues? Or should an entirely different group of experts and interested parties be gathered for this purpose? "If clinical ethics committees are going to expand to organizational ethics, they need to at least revisit their composition," she continues. "If there are not budget people, planning, marketing, and human resources people on the committee, they won’t be prepared to take on these issues."
Implementing organizational ethics requires more that hospitals adopt a new overall framework than they set aside a new committee to look at those issues separately, says George Agich, PhD, chairman of the department of bioethics at the Cleveland Clinic. "There has to be more of a way of including the ethical perspective in all decisions," he says. "So, we are not considering the moral implications separately, but that they are considered at the same time."
And, Agich says education of the key decision makers at the hospital’s highest levels is necessary. "Ethics committees cannot just decide that they want to do organizational ethics’ and not have the support of the executives and board, it won’t work," he says.
Essentially, it’s up to the key decision makers to balance the tension between the market values and the professional values, agrees Neale. "In our lexicon of values, the market values should serve the professional values," she notes. "If at the board level, the management level, and the departmental level, we are always honoring the market values without attending to what they are doing to the professional values, we are in jeopardy of the organization’s losing its integrity. I am not saying there aren’t situations in which the market value necessarily has to win out over the professional value, but if it does, it should be done with eyes wide open, knowing that it regrettably makes it impossible to fulfill your obligation to the community in some way."
• George Agich, Cleveland Clinic Foundation, Department of Bioethics, NA10, 9500 Euclid Ave., Cleveland, OH 44195.
• Carolyn Ells, Dalhousie University, Department of Bioethics, 5849 University Ave., Halifax, Nova Scotia, CA B3H 4H7.
• Ann Neale, Center for Clinical Bioethics, 4000 Reservoir Road N.W., Bldg. D, Room 234, Washington, DC 2007.