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Foundations for Ethics

Foundations for Ethics

- 1 ability to pro ’s A must also apply that ethics that also apply must must also be prepared to go go to also be prepared must . In this introduction, consider consider this introduction, . In based health care? First, HCAs HCAs First, ­based health care? HCAs HCAs (HCAs) ealth care is in a constant state of change and challenge, challenge, and change of state in a constant is ealthcare this Therefore, future. its into continue to likely which is true rings , , the ancient from quote To address these concerns, these concerns, address To change, great a of In How does this climate of change affect the HC change of does this climate How Introduction ▸ SECTION I SECTION consider individual, organizational, and societal and viewpoints. organizational, individual, consider this epoch of change. thischange. epoch of needs of thebusiness to respond They must care. patient beyond organization, staff members, the patient, respect to with health care basea in have to HCAs requires challenge This the community. and addition, skills. In and their professional apply ethics and ethics through of deepera application mandate thesechallenges that and both personal maintain that behaviors appropriate their organizations. of an example of how change can affect care and its ethics. For example, example, ethics. For its and affect care can change how of example an effective efficient and more technology of growth the rapid improve and healthconditions treat to the ability with along care also outcomes impressive technology’s Of course, outcomes. finance, of in the areas health administrators for challenges bring demands. patient staffing, and vide both fiscally ethics- and sound receive patients where environment an providing need continue to they must addition, In care. compassionate and both appropriate structure system healthcare the complex support and adapt, create, resources, future and current of stewards As change. to responds that they that ensure and these resources protect to required are HCAs in increase only can These serious responsibilities used ethically. are Ethics it or not. want we Change happens whether ▸ administrators healthcare for Foundations for for Foundations H

© Panuwat Dangsungnoen/EyeEm/Getty Images 2 Section I Foundations for Ethics

To meet this challenge, they must be informed by both qualitative and quantita- tive data to make decisions that are both fiscally sound and ethically appropriate. In this epoch of change, ethics becomes more than a course that is forgotten upon graduation. It is an essential for the successful practice of healthcare administration.

▸▸ A Word About the Text The Fourth Edition of Ethics and Health Administration: A Practical Approach for Decision Makers contains chapter revisions and new chapters to reflect the current state of health care. For example, Chapter 5 is new and is titled Ethics in the Epoch of Change. It discusses changes in healthcare and how they challenge ethics decision-making. HCAs use theories and in their decision-making and daily prac- tices. Therefore, this new edition begins with a foundation in theory and prin- ciples. It goes beyond theory to application by including discussions, examples, case studies, and exercises within its chapters. These inclusions are designed to increase a deeper understanding of how to make ethics an integral part of the administrative role. Each chapter contains a “Key Terms” section to build recognition. Chapters also include case studies. These stories are based on fictionalized situations from many different healthcare . Feedback from past students indicates these cases are helpful in applying ethics to . The model seen in FIGURE I-1 guides the organization and vision of this text. Since HCAs do not make decisions in a vacuum, the circle organizes its themes and reflects how ethics influences healthcare practice. The outer circle represents the theory and principles that form the foundations for ethical decision making. The next circle represents areas external to the organization that influence the operations of healthcare administration. Internal influences are represented by the next circle in the model. These factors strongly impact the day-to-day practice of ethics in an organization. Finally, the inner circle represents the HCA’s personal ethics and its influence on action and career success. The circle model also serves as an organization plan for the chapters in the book. For example, the Foundations for Ethics section establishes a base in ethics theory and principles. The Practical Theory chapter explores founding theories of ethics that guide most of Western ethical thinking and includes a new section on the theory. Using this theoretical groundwork, the chapter explores one of the four key principles of healthcare ethics and discusses how it influences the practice of health care. The Nonmaleficence and Beneficence and Jus- tice chapters focus on the remaining key principles and their relevance to healthcare administration. And a new chapter, Ethics in the Epoch of Change, examines the of healthcare, the changing healthcare culture, and ethics challenges during major change events. In the External Influences on Ethics section, the Market Forces and Ethics chapter considers the influence of various markets on the application of ethics in healthcare administration. The Healthcare Regulation and Ethics chapter addresses the relationship between regulation and ethics. It also includes advocacy and staff Section I Foundations for Ethics 3

Personal Ethics

Internal Influences

External Influences

Founding Principles

FIGURE I-1 A System of Healthcare Administration Ethics competency in relation to ethics theory and principles. Finally, the Technology and Ethics chapter presents an updated and in-depth view of technology’s impact on ethics decision-making, including emerging technologies. The healthcare organization’s influence on an administrator’s ethical deci- sions is the focus of the Organizational Influences on Ethics section. The No Mis- sion, No Margin: Fiscal Responsibility chapter presents the challenges of finance and its influence on ethical decisions. It also presents ethics issues related to the challenges of financing healthcare, nonprofit versus for-profit healthcare organi- zations, and of finances. The Healthcare Organizations: Culture and Ethics chapter features on important patient culture and ethics chal- lenges. There are also discussions about professional culture, ethics committees, and models for decision making. The next chapter, The Ethics of , is especially important in of great change. It presents information about the organization’s response to quality and the of quality itself. In light of health care’s patient empha- sis, The Patient Issues and Ethics chapter considers the organization’s responsibil- ity to meet changing patient needs and expectations. This topic is presented from both the patient and organizational perspective. The Public Health and Ethics presents information on public health in action in the epoch of change and how it affects both community health and the healthcare system. It also introduces the mission of public health and professionals who are part of this important aspect of healthcare delivery. The Personal Ethics and chapter investi- gates morality and its for the busy HCA. It also includes discussions about the effects of ignoring morality and how to practice personal ethics as an administrator. 4 Section I Foundations for Ethics

The Inner Circle of Ethics section discusses how HCAs use ethics in their professional practice. The Codes of Ethics and Administrative Practice chapter provides an overview of organizational and professional codes of ethics and their application to administrative practice. Finally, Practicing as an Ethical Admin- istrator chapter relates to the difficulties maintaining one’s base in ethics as an administrator who practices in a time of great change. It offers practical advice for balancing ethics with expediency and change. This new edition assists readers in seeing the world through “ethical eyes” as well as through financial ones. By applying ethics, one can enhance the overall effec- tiveness of one’s organizations and better meet challenges in a -based industry. On a personal level, one can become a of integrity with a reputation for practical wisdom. One can make decisions that are both fiscally sound and ethically based. In the end, ethics always . © Panuwat Dangsungnoen/EyeEm/Getty Images

CHAPTER 1 Practical Theory

Healthcare administrators without grounding in ethics theory are like boats without rudders. They keep going around in circles and go nowhere.

KEY TERMS

The following is a list of this chapter’s key terms. Look for them in bold. Act Natural ethics Conventional Practical wisdom Deontology Preconventional Ethical Premoral Ethics of care Principled Rule utility I–THOU Sense of meaning Maximum principle Moral development

▸▸ Introduction and Definitions ou watch your house fill with water as you enter a rescue boat. You visit your grandmother in a nursing home and you can still hear her asking to go home. You have to inform your staff about a new policy on infection control. You Yhave to explain the copayments to a patient who is full of fear about her surgery. What do these scenarios have in common? First, they deeply connect to the core of all of health care—trust. From the patients’ view, trust happens on both physical and emotional levels. For example, patients surrender their privacy, bodies, and even their lives for care and expect to have a quality outcome. They expect providers and those who address the business of health care to honor their trust, including treating them with respect and . In the administrator role, trust is the basis for creating policies, procedures, workflow, and mechanisms that make health care happen. Healthcare administrators trust that healthcare personnel will provide competent care, serve patient needs, and

5 6 Chapter 1 Practical Theory apply facility guidelines. In addition, they must also be aware of the needs of patients and fiscal responsibility and respect the autonomy of healthcare professionals. How does this information relate to ethics? To the outside world, administra- tion seems to be about policies, procedures, billing, patient satisfaction numbers, and compliance. While these areas are certainly relevant to the practice of healthcare administration, the center of its practice is making the best ethical decisions for patients, providers, and the organization. Because of the unique nature of health care, administrators must also be able to combine fiscally sound decisions with ethical practices. Decisions must also comply with regulation, standards, and oversight efforts. In addition, healthcare administrators must defend their decisions to a myriad of audiences, including healthcare professionals, boards of trustees, community members, and agencies. Certainly, making decisions that foster efficient and effective health care that is also ethically sound in not easy and requires knowledge and skill. From an ethics standpoint, the first step to apply ethics in decision-making is to understand its definitions, theories, and principles. Therefore, this chapter begins with a section that presents examples of definitions associated with ethics, including ethics theory. Many sources provide deep exploration into the work of the ethics scholars; however, it is not possible to study all of their work in one comprehensive text. Therefore, the author chose eight key theorists who were instrumental in cre- ating the foundation of ethics that relates to health care. This text provides a basic understanding of the key points of their theories, including their background and the application of their to healthcare settings. However, is encour- aged to go beyond this summary. To assist readers in their ability to apply theory to practice, the chapter begins with a brief biography of each theorist. This is followed by a summary that features a working knowledge of one’s theory. Finally, this chapter includes information on the application of the theories and additional resources for enhancing the learning process.

▸▸ Definitions of the Word Ethics For this chapter, (how one decides right from wrong) is featured because it relates to the application of theories and principles to practice. In addi- tion, normative ethics assists in determining appropriate rules for decision-­making (Summers, 2019). Darr (2011) explained that the definition of ethics involves more than just obeying the law. Law provides the minimum standard that approves for actions or behaviors; ethics is broader and much more difficult to practice con- sistently. Therefore, a person could behave legally but not ethically. Administrators must also consider the community’s definition of appropri- ate ethical behavior for individuals and organizations. This definition may not be founded on a theoretical framework, but “they know it when they see it.” Therefore, administrators understand community standards in making decisions and apply ethics as more than a carefully worded mission, , and vision statement. Normative ethics is also concerned with organizational ethics, which is com- monly defined as “the way we do things here.” Knowing how organizational eth- ics is applied assists the understanding of acceptable behavior and action within the organization. However, healthcare organizations do not create operational Ethics Theory and Its Application 7 definitions of ethics—people do. Therefore, creating organizational ethics stan- dards must include a about differing views regarding ethics and the for- mation of operational definitions. Professionals provide health care and come from a variety of practice orienta- tions. Healthcare administrators have the responsibility of the quality of care that these professionals provide. Therefore, it is necessary to understand how health pro- fessionals define ethics in their practices. Their standards of are created when their professions establish definitions and guidelines for ethical behav- ior. This process typically results in a code of ethics. For example, different codes of ethics exist for nurses, physicians, physical therapists, occupational therapists, massage therapists, acupuncturists, and counselors. For their profession, healthcare administrators have guidance from the American College of Healthcare Executives (ACHE) on definitions of ethics, concepts of ethical behavior, a code of ethics, and policy development. Of course, the practice of ethics is about people. To practice ethics as admin- istrators, HCAs must consider theoretical, patient, community, and organizational ethics as they make decisions. They also have to be attuned to their own professional standards and those of the professionals who are part of their organizations. How- ever, in their function as administrators, individuals must also own their decisions. Some might ask, “Isn’t ethics just doing what is right at the right time?” The answer is “yes, but….” In healthcare organizations, what is right is not always a simple matter. In developing ethics-based decisions for the bottom line, HCAs need to con- sider . This form of ethics has its base in the that actions should center on what will provide the best personal benefit (Summers, 2019). In other words, a person has the right to consider his/her own interests and benefits when making decisions. This idea is important when patients make decisions about their health care. However, in the healthcare system, the needs of all patients, employees, the organization, and the community must be considered as well. Healthcare administrators are representatives of the mission and values of their organizations for the community. To be prepared for this role, they must understand both the ethics position of their organization and the community they serve. To best achieve this goal, health administrators must begin with the mission, vision, and values of their own organizations at a practice level. In addition, they must also investigate the ethics orientation of organizations that regulate their business, staff that serve their patients, and their own code of ethics. Finally, they must consider their personal values and ask themselves, “What is my ethics bottom line?” After considering all of these ideas, the HCA should create a personal ethics statement. This statement could serve as a guide in making the difficult decisions that are often part of health administration.

▸▸ Ethics Theory and Its Application While there are many ethics theorists, eight are included here because of their influ- ence on health care. They include Aquinas, Kant, Mill, Rawls, , Buber, Kohl- berg, and Gilligan. For the purpose of this discussion, these theorists are divided into two groups. The first group, which includes Aquinas, Kant, Mill, and Rawls, examined the global issues surrounding ethics and ethical decisions. The second 8 Chapter 1 Practical Theory group, which consists of Aristotle, Buber, Kohlberg, and Gilligan, studied personal ethics and moral development. This chapter provides a summary of their works to assist in understanding their contributions to health care.

▸▸ Global Ethical Theories St. (1225–1274) Biographical Influences on His Theory According to family tradition, St. Thomas Aquinas, the youngest of four boys, was destined for a career in the church. Between the ages of 5 and 15, he served in the local Benedictine abbey and his family had great ambitions for his role in the church. They made sure that he was well instructed in the classic literature of his time. For example, during his studies at the University of Naples, he read a newly discovered version of Aristotle’s work, which influenced his thinking on many levels (Brown, 2018). Early in his life, St. Thomas received a calling to become a member of the Dominican order of the . However, his family did not support this vocation and tried to prevent him from joining the order. They ordered his brother to bring him back to their castle and placed him under house arrest. When he would not renounce his calling, they tempted him by sending a prostitute to his room. Aquinas chased her out and slammed the door on her. Finally, his mother relented and allowed him to go to Cologne, join the Dominican order, and continue his study with the major scholars of his day (Brown, 2018). Aquinas became a teacher of and prolific ; the greatest of his writings in ethics was the Summa Theologiae. Part Two of this work was devoted entirely to ethics and combined Aristotelian and Christian thinking. This work helped establish the concepts of (McInterny & O’Callaghan, 2016; Summers, 2019). St. Thomas was canonized in 1323 and his works have influenced in every century.

Concept Summary Influenced by Christian theology and the writings of Aristotle and others, St. Thomas Aquinas’s was that he brought together , divine inspiration, and (Palmer, 2010). According to Aquinas, is perfectly rational and He created the world in a rational manner (Summers, 2019). God also gave the ability to reason, evaluate what is or , and make rational decisions. This ability for rational decision making is part of AQUINAS concept of natural law. Because humans have this gift, they have the potential to use moral judgment and choose good or evil (Darr, 2011; Palmer, 2010). Notice the word “potential.” This means that choosing good over evil is not automatic. Aquinas noted that people may violate natural law because they are also given the gift of . However, if people are true to their rational , they will listen to their (i.e., the voice of God) and obey natural law by choosing goodness over evil. How does Aquinas define goodness? His definitions stressed that the gift of contributed to choosing what is good. Acts that preserve life and the race are part of his definition of good. An action is also good if it advances knowledge and , helps people live in community, and respects the of Global Ethical Theories 9 all . Aquinas also believed that to find , people must not look at pleasures, honors, wealth, or worldly power because these are not the true source of goodness. Truly understanding God is the ultimate good that all rational human seek (Kerr, 2009). Aquinas also presented what he called four cardinal , which included prudence, , temperance, and courage. These virtues are cardinal because they lead to actions that produce good. For example, prudence leads to making good judgments that positively affect the person and others. Temperance as con- strains excessive ambition and greed. Courage restrains fear so that individuals can make decisions that benefit others. Justice influences policies and procedures that provide what patients need and considers more than legal requirements.

Theory Applications How do Aquinas and his position on ethics apply to today’s world? Do you think people can choose to act against their “rational nature” (as defined by Aquinas) and cause harm to themselves and others? For example, it is not rational to text while driving. If people make this irrational decision, their actions can cause them harm to themselves and others or even death. In contrast, making rational decisions about one’s health benefits the quality of one’s life. For example, if everyone made the ratio- nal decision to protect themselves from the flu, it would reduce the overall cost of healthcare for the community. Aquinas’s idea of “basic good” seems to be simple on the surface. All a person has to do is use reason to make the best , respect people’s dignity, and help them live in community. However, when one translates this concept into the health- care system and its policies, matters become much more complex. Does health care have an to those who do not make rational choices? Do they deserve the same level of care as those who make rational choices, or should they pay more for care because they are not making rational choices? How can the business of health care preserve the human race and still have enough money to keep its doors open? In the current healthcare environment, will these questions be even more difficult to answer? (1724–1804) Biographical Influences on His Theory Immanuel Kant was born in Königsberg, , and was the son of a harness maker. His family was deeply religious, with an orientation toward piety and hard work. Kant completed initial studies at Königsberg University but did not have the finances to complete higher-level studies. In order to finance his education, he worked as a tutor for wealthy families. Once he completed his studies, he was accepted as an instructor at Königsberg University and taught there for over 40 years (Rohlf, 2016). Kant began to publish in the area of and moral philosophy and his interest in , , and enlightenment led to his fame as a major German philosopher. His works include Groundwork of the Metaphysics of Morals (1785), of Pure Reason (1787), and Critique of the Power of Judgment (1790). Kant’s work centered on ideas of autonomy, how the world should be, and one’s to make the world be as it should be (Rohlf, 2016). 10 Chapter 1 Practical Theory

Concept Summary Kant’s writing in metaphysics and later on practical philosophy had a major impact on the field of ethics. He went beyond the description of what the world is (theoret- ical philosophy) to a discussion of what the world should be (practical philosophy). Through his thinking about morals and reasoning, Kant founded an entire area of ethics called deontology, or duty-based ethics (Summers, 2019). To understand Kant’s theory of deontology, one must understand the idea of duty and the standards that determine a person’s duty. When an action is a moral duty, an ethical person seeks to meet this duty. However, Kant also stressed that there must be a way to identify one’s moral (Summers, 2019). In order to understand moral duty, Kant considered the idea of what makes something universally good. He studied areas such as talent, , money, and even happiness and determined that they are not good in themselves. Rather, a per- son can use any of these assets for good or evil. While society may value personal and intellectual attributes, any of socially acquired or genetic attributes are also not intrinsically good (Blackburn, 2001). Then, what is a good? For Kant, the only good that can exist without clarifi- cation is something called good will. Acting with good will means that no ultimate end exists for the person who chooses it; it goes beyond what might be determined as a duty. In other words, acting with good will does not benefit those who choose to take such actions. They choose to do what they consider is the right thing to do. They are motivated by an inner sense of duty rather than any external influence or -interest. This inner understanding of their sense of duty motivates them; it is motivation that counts. Therefore, good will is not a means to an end; it just is (Blackburn, 2001). In the Kantian view, all humans have absolute worth simply because they exist. Because they have worth, they are not a means to accomplish what an individual wants or to meet a societal goal. Rather, they are an end in themselves. What does this mean in practice? For administrators, it means that they cannot use people as a way to get what they want and remain ethical. For Kant, it was also important to respect the dignity of others, including , autonomy, and rationality (Palmer, 2010). How does this translate in health care? It means that there is a duty to act in moral ways and consider this duty in their choices. How do healthcare professionals know what is good and what is not? First, Kant acknowledged that all people have the ability to think and make their own decisions. In , he said free will was essential to ethical behavior and to understanding what is good (Summers, 2019). Kant also acknowledged that humans are rational and can use reason to decide what rules apply to good. Kant provided a tool to determine moral duties called the categorical ­imperative. This tool serves as vehicle to test actions, determine one’s duty, and make moral decisions. For Kant, decisions about duty-based ethical choices included application—that is, a universal law. For example, an adminis- trator can ask, “Would I want everyone to be able to do this without exception?” If the answer is “yes,” then the decision passes the test of universalization or the categorical imperative. It then becomes a categorical moral duty and carries a moral obligation to act in accordance with this duty (Blackburn, 2001; Palmer, 2010). The categorical imperative has been compared to the (a part of many of the world’s ). Kant, however, that it differed from the idea Global Ethical Theories 11 of “do to others what you would do to yourself.” For example, one could apply the Golden Rule in ways that are not universal if feelings and needs, rather than rea- soning, are used to determine actions. In his test, moral duty goes beyond people’s determination of fairness. For example, administrators who apply the categorical imperative would be required to treat patients, staff, and others as individuals and not as a means to an end (Blackburn, 2001; Palmer, 2010; Summers, 2019).

Theory Applications Kantian, or duty-based, theory can apply to many situations in health care. One could agree that all human beings should be means unto themselves and deserve respect. All people in one’s daily work life—employees, patients, community mem- bers, and others—have absolute value simply by the fact that they exist. Just because they can accomplish more or less in society’s eyes does not change their value as human beings. This leads to the idea that for moral decision making in health care, all persons in similar circumstances deserve the same respectful treatment. In addition, Kant’s categorical imperative assists in defining the moral obliga- tions. Therefore, this tool can be useful in determining moral duty when develop- ing healthcare policy and procedures. For example, when one develops a personnel policy, one can ask, “What is the reason behind this policy? Can this policy apply to everyone as it is written?” Using the categorical imperative, the answers to these questions can assist in determining whether the policy is universal. Making this determination can also assist in the implementation of the policy and avoid act util- ity versus rule utility. Despite Kantian theory’s base in good will, one can see that a strict Kan- tian might be a difficult for the HCA. To follow Kant in the strictest sense, an admin- istrator should make decisions based on good will and not on profit, legal mandates, or pleasing stakeholders. Because these are factors in the business elements of health care, they must be considered when making policy and business decisions, but they do not negate the worth of individuals. In addition, Kantian moral theory may not provide answers to all of the complex issues in today’s healthcare system. For exam- ple, if a researcher uses human subjects to help find the cure for cancer, is he or she not using those individuals as a means to an end? Does this fail the categorical imperative test? In a strict Kantian sense, one could say that it does, yet there is potential benefit to a larger group from the knowledge gained.

John Stuart Mill (1806–1873) Biographical Influences on His Theory is one of the most influential ethics theorists in American health care. Born in London, he was the son of , a historian and economist. Mill’s father maintained strict discipline with respect to John’s learning; he studied Greek at age three. At 15, Mill studied major works of philosophy and . Influenced by Bentham’s utility concepts, he began to write his own theory of utili- tarianism before he was 20. However, his high level of achievement and intellectual activities led to a mental crisis (Macleod, 2017). He was able to recover from this crisis because of his ability to explore new areas, including , philosophy, and reform. Mill became a Member of Parliament 12 Chapter 1 Practical Theory and represented the . In this role, he supported social causes, including suffrage for women (Wilson, 2007). Some of Mill’s major works on ethics include ­System of , .

Concept Summary Based on the idea of telos, or ends, Mill’s theory of utilitarianism forms the eth- ical justification for many American healthcare policies. His moral philosophy is based on the idea of utilitarianism or consequentialism, which posits that that one should base ethical choices on their consequences and not on one’s intent or duty. When applying Mill’s utilitarianism concepts, administrators weigh the conse- quences of those actions and their effects on others’ happiness rather than on their intent or method. The results of this evaluation often influence healthcare cost anal- yses, policies, and practices (Darr, 2011). How does one determine the utility of consequences? According to Summers (2019), Mill’s evaluation of utility began with the assumption that respect for indi- vidual autonomy is implied when seeking the greatest good. With that in , administrators must consider actions that give the greatest benefit (or happiness) to the greatest number of those affected by the consequence or decision. A decision is not ethical if it produces the greatest harm for the greatest number of those affected. Thus, the focus of an ethical decision is based not on the individual person or on the person’s intension, but rather on the best outcomes for all persons. often reduce Mill’s theory to the phrase “the greatest good for the great- est number” (Summers, 2019, p. 26). While this is a concise summary of the theory, it does not consider the idea of preventing the greatest harm to the greatest number, which is also part of utilitarianism. Preventing harm increases the opportunity for the greatest good and provides a rationale for policies related to disease prevention and reduction (Darr, 2011). Ashcroft, Dawson, Draper, and McMillan (2007) pro- vide examples of the greatest good for the greatest number in healthcare settings, such as public health, quality of life efforts, and the work of healthcare economists. In addition, utilitarianism, in contrast to Kantian theory, allows a person to be a means to an end. However, this should occur only when there is a greater good. For example, suppose an individual decides to part of an experimental treatment that will not provide a cure for his ailment. However, he can contribute to cures for future generations. While he/she becomes a means to an end, the consequences of his/her decision create a greater good. Healthcare administrators are often challenged to analyze consequences for their decisions by considering the utility of their consequences (Purtilo & Doherty, 2011). Their analysis can be assisted by dividing utility into two main groups. The first type of decision is to use act utility. This means that each decision is evaluated for its consequences and the decision based on its own merit. There is an analysis of the consequences for that specific case and, based on this analysis, one makes a deci- sion. Also called classical utilitarianism, act utility is not always practical for health- care administrators. The decisions that they make are often numerous, complex, and interrelated. For example, an exception for a personnel policy that is created for the greatest good of one person may not have merit for others (Summers, 2019). The second type of decision-making using Mill’s theory is based on rule ­utility. With this approach, administrators assume that using rules (or policies) Global Ethical Theories 13 provides the greatest benefit. They analyze the potential consequences of a decision before making a final decision on its action. This form of utilitarianism appeals to healthcare administrators because it allows for decisions that will be the best in most cases and contribute to the process of cost/benefit or gain/loss analysis for justifying decisions.

Theory Applications Many healthcare administrators perceive Mill’s utilitarian principles of ethics to be a practical way to address the difficult decisions that are inherent in health care. Resources are never unlimited in health care; therefore, there is a need to make decisions based on universal benefit. Using the balance sheet approach of rule util- ity identifies consequences, determines merit, and assists in making a decision that will benefit the most number of people who are affected. Hopefully, this approach should make cost-benefit and ethics-based decisions easier. The ability to ignore the needs of the minority to provide the greatest good for the majority is a limitation of Mill’s theory. In rule utility, the individual is not the focus of moral decision making; it is concerned with the greatest benefit to the greatest number of people. However, in using this decision-making, an administra- tor could violate the or needs of the individual. Summers (2019, p. 27) refers to these situations as the “tyranny of the majority.” An example might clarify this point. Suppose an administrator created a policy and funded a screening program that served all the members of a community. This would seem to benefit the greatest number of people and meet the requirements of rule utility. However, to find the funds for this program, the administrator elimi- nated funding for a program that served a small group of uninsured patients who needed counseling. The funded program might provide the greatest good for the greatest number, but those affected by the defunded program might have good rea- son to disagree with its value.

John Rawls (1921–2002) Biographical Influences on His Theory ’s father was an attorney and his mother was active in the League of Women Voters. He attended an Episcopal preparatory school before beginning his studies at Princeton and Oxford. These studies led to his consideration of a vocation in priesthood. However, what he witnessed as an infantry soldier during World War II put a great strain on his faith. Perhaps his upbringing, education, and experiences influenced his concern with and the integration of politics and ethics (Wenar, 2017). Rawls taught at Princeton, Oxford (Fulbright Scholar), and Massa- chusetts Institute of Technology. In his final academic appointment, he served as a professor at Harvard University for 40 years. Rawls was concerned about justice within a society and the relationship between justice and fairness. His work, (1971), was centered on the relationship between a just society and its actions. His work in social justice continues to influence modern political, social, and ethical beliefs on how to define a just society (Wenar, 2017). 14 Chapter 1 Practical Theory

Concept Summary Rawls’s theory was founded on what constituted a just society and fair treatment. It included egalitarian principles that addressed issues of moral equality and just treat- ment (Beauchamp & Childress, 2013). Rawls studied the previous works of philoso- phers and formulated his own theory of justice that included the concept of “justice as fairness” (Summers, 2019, p. 20). What does this phrase mean? To explain his ideas, Rawls set up a hypothetical situation in which everyone is equal. He called this scenario the “original position” (Summers, 2019, p. 21). He also asked that a person assume the “veil of ignorance” (Summers, 2019, p. 21). In this situation, people would not know their “individual talents, , and social and economic situations” (Darr, 2011, p. 20). Given their original position and veil of ignorance, people would act to protect their own best interests and want everyone to be treated fairly (Blackburn, 2001). On a societal level, protection of self-interests would require a to assure fair treat- ment for everyone (Rawls, 1999; Summers, 2019). This contract, as part of a just soci- ety, would identify what is necessary to protect the rights and self-interest of others. Rawls also defined something called the liberty principle (Darr, 2011), which means that all people should have the same basic rights as all others in a society. For example, if the rich have a right to basic education, then so should everyone else. To be just, people must also address inequalities in a society to protect those who are in a lesser position. Although Rawls did not specifically address health care, this principle is used in healthcare policy and decisions related to children, poverty, and medical problems that affect quality of life (Beauchamp & Childress, 2013; Vaughn, 2010). In Rawls’s view, everyone has the potential to be in a lesser position. There- fore, acting to protect the rights of those who are less well off is actually part of one’s self-interest. In addition, need to take action to maximize efforts that benefit those in a lesser position. Rawls included actions to address inequalities in his maximum principle. Further, social problems tend to be suffered more by those who are in lesser positions. For example, persons who are living in poverty are also more likely to be victims of crime or have more severe health problems. In addition, when people in a society are not treated for health problems, this failure can affect the entire society. For example, if a person has a communicable disease and does not receive treatment, that disease can infect others. Therefore, it is in everyone’s self-interest to provide prevention and treatment. Rawls had a second principle of justice, called the principle, which addressed inequalities in the society. He postulated that differences and advantages exist in economic and social position but in a just society, the differences should provide benefit for that society. For example, a physician is paid more than others in a society and has greater status. However, this difference includes a responsibility to benefit those were in a lesser position by the application of their knowledge and skills (Beauchamp & Childress, 2013; Summers, 2019). Rawls also addressed fairness of providing necessary services or benefits. He felt that it was rational and morally right to limit services when there is a greater need among certain groups. “It is also rational and self-interested for persons in the original position not to make every good or service available to everyone at all times” (Darr, 2011, p. 20). Therefore, health care can be limited for some groups, but this limitation must provide benefit for those who are in a lesser position in society. Personal Ethical Theories 15

For example, when a patient goes to the emergency department with a sprained ankle, there are many services available to diagnose and treat that person. However, the patient might not get immediate treatment or even the use of all of the available treat- ments. If a person with life-threatening conditions is simultaneously present in the emergency department, he/she would be treated first and with greater resources. It is in the self-interest of all who have healthcare needs to understand that those in critical situations receive treatment first. This is true because people assume that if they were in this position (lesser position), they would receive the same priority treatment.

Theory Applications Rawls’s ideas about social justice greatly influenced political thinking, including the treatment of those in a lesser position. He used terms such as natural lottery and social lottery to explain how people can be in a lesser position (Beauchamp & Childress, 2013). He also believed that talents and disabilities could be the result of one’s biology and heredity (natural lottery) and one’s family status and wealth (social lottery). If a person does not enjoy the positive end of the lottery, he or she may be in an undeserved disadvantage. A just society would make an effort to address these disadvantages in an ethical manner. One can see the influence of Rawls’s thinking in programs such as Head Start and Medicaid/Medicare. Likewise, his theory has ramifications for many U.S. institutions, such as education and public health. According to Beauchamp and Childress (2013), Rawls’s ideas about social jus- tice motivated other writers such to consider fairness in providing access to health- care. In addition, he influenced research related to inequalities in health and their impact on indices of health, such as life expectancy. Rawls’s theory also supports the idea that “justice is a fundamental virtue of institutions” (Purtilo & Doherty, 2011). This means that healthcare organizations have an obligation to the just use of resources and respecting all that they serve. While patients are the obvious target for this respect, healthcare organizations have a responsibility to the community and the environment. An example of this responsibility would be the use of financial and physical resources in ways that avoid waste and a safe environment for patients and employees (Purtilo & Doherty, 2011). However, the ethical challenge is not just in meeting the standards of Rawlsian justice. Within this challenge, there is also a need to maintain a healthy bottom line so that doors stay open and salaries are paid. Addressing this challenge requires ethical stewardship in a complex environment and in an ever-changing healthcare system. Integrating the principles of justice and fairness introduced by Rawls with those of fiscal responsibility will continue to present a major challenge for healthcare institutions now and in the future.

▸▸ Personal Ethical Theories The section presents a consideration of personal ethical theorists. These theorists focused on individuals and their ethical and moral behavior and explored how they acquired their moral reasoning. The section begins with Aristotle, who provided a foundation for many of the great who followed him. is included because he described personal ethics in terms of moral relationships. Law- rence Kohlberg also examined personal development of ethics by looking at stages 16 Chapter 1 Practical Theory of development. Finally, , a student of Kohlberg, approached moral development through the importance of relationships.

Aristotle (384–322 bce) Biographical Influences on His Theory Aristotle was one of the greatest philosophers of his time and is still an influence on writers in the current century. A child of privilege, he was sent to Athens to study with at the age of 17. He remained part of Plato’s academy and continued his study for over 20 years. In 343, the king of Macedonia asked Aristotle to tutor his son, who later became Alexander the Great (Kraut, 2017). Aristotle set up his own academy and also wrote more than 200 works in the areas of , logic, psychology, botany, metaphysics, politics, and ethics. He was also an innovator. For example, he was the first to write specifically about applying virtue and moral thinking to ethics decisions. Despite his fame, Aristotle faced a life-threatening situation. While he was living in Athens in 323, Alexander the Great died. Because of this death, he feared for his safety and was forced to leave the city (Kraut, 2017).

Concept Summary Aristotle’s study of included principles for living a virtuous life. His definition of virtue derives from the Greek word areté, meaning “excellence.” This theory included information about how people made moral decisions in their lives. For Aristotle, people build their moral character through their decisions and by practicing both intellectual and moral virtues. In addition, virtue, practical wisdom, and eudaimonia were part of Aristotle’s concepts for living a moral life (Blackburn, 2001; Palmer, 2010; Summers, 2019).

Virtue Following in the footsteps of and Plato, Aristotle believed that a well-lived life was one that was concentrated on virtue. This life went beyond meeting inner for happiness. It required the human ability to advance one’s intellect and reason and take action based on virtue (Blackburn, 2001). In addition, the to make virtue a habit was a requirement. Examples of virtue include practicing temperance, exhibiting courage in adversity, and providing assistance to someone without personal reward (Blackburn, 2001; Palmer, 2010).

Practical Wisdom Since building a virtuous character requires action and choice, Aristotle included the concept of practical wisdom or phronesis as a way to make choices that lead to virtuous decisions (Summers, 2019). Using practical wisdom allows healthcare administrators to practice the “virtue of discernment” (Beauchamp & Childress, 2013, p. 39). This means that administrators can choose the best action without being influenced by fear, relationships with others, or personal considerations. Using practical wisdom also allows administrators to apply policies and rules that are balanced by principles of ethics. Personal Ethical Theories 17

Ethical challenges increase as administrators face the ever-changing healthcare system. This dynamic change indicates that there may not be a policy or answer in all situations. Therefore, healthcare administrators can apply Aristotle’s practical wisdom to discern the best action for the situation. Using practical wisdom requires that they need to be stronger than their impulse to act before they analyze. Discern- ment requires an assessment of how choices affect people in different situations and also how they reflect the mission of the organization. Using discernment, adminis- trators can be guided by their investigation and character to choose the best option for the current situation. This option is often the middle ground. Practical wisdom can be also applied to groups and communities as they attempt to choose the best action for their situations. As Beauchamp and Childress (2013, p. 39) reminds, “the virtue of discernment brings sensitive , astute judgment, and understanding to bear on action.”

Eudaimonia Eudaimonia has been translated as happiness or the idea of flourishing (Summers, 2019). However, the idea of modern definition of happiness does not explain what Aristotle meant by this term. Happiness in the modern sense is often interpreted as personal happiness. Instead, Aristotle’s concept of eudaimonia included the choice to live life as it was intended to be—that is, a life lived by practicing virtues and working to build one’s moral character. This choice requires the ability to contem- plate and address difficult issues and how to live together in community. It also means that a person is concerned about living with others, developing personal excellence, and “becoming a person of character” (Summers, 2019, p. 9).

Theory Applications Aristotle’s theory has applications in today’s healthcare environment and the social- ization of professionals. Those who choose to be part of the healthcare system are educated in areas beyond their knowledge and skills. They must also be persons of moral character and virtue. They build their professional moral character through professional socialization (Summers, 2019). For example, Beauchamp and Childress (2013) include an entire chapter on the moral character of those who choose careers in the health professions. They feature “five focal virtues for health professionals: compassion, discernment, trustworthiness, integrity, and conscientiousness” (Beau- champ & Childress, 2013, p. 37). These virtues are linked to a healthcare profes- sional’s ability to care for patients and the morality or excellence that is expected by patients, families, and communities.

Martin Buber (1878–1965) Biographical Influences on His Theory Martin Buber was a scholar and an activist in the Zionist movement. He spent much of his childhood with his grandparents in a traditional Jewish community where his grandfather was a well-respected and scholar. Buber’s extensive educational background included being fluent in Hebrew, , Polish, German, Greek, , French, Italian, and English (Zank & Braiteman, 2014). 18 Chapter 1 Practical Theory

In 1933, Buber served as the Director of the Central Office for Jewish Education during a time when Hitler would not allow Jews to go to school. In 1937, he was offered a position at Hebrew University in , an institution that he helped found. One of his most important works on philosophy and ethics is (1996). This book began as a commentary on , but is now applied to ethics, psychology, medical , and politics (Zank & Braiteman, 2014).

Concept Summary Buber’s powerful book, I–THOU (2010) centered on the idea of relationships and how they affect what it means to be a human being. In his book, he proposed that human beings need meaningful relationships and communication to survive. He began his study of relationships by defining the “I,” which is unique to human beings. Humans are capable of having relationships because they have the ability to recognize each other and the world. Humans are also capable of having dialogue in their relationships with others, and these variations demonstrate the depth of communication and understanding. Buber described the “I” as a singular human being. All humans are viewed as “I,” but development in understanding who they are requires the ability to relate to others. This ability includes communicating with fel- low human beings, nature, and God (Scott, Scott, Miller, Stange, & Crabtree, 2009). Buber also described relationships as existing in pairs (Buber, 2010). These pairs reflect depth of relationship and communication. The least effective human relationship is the “I–I” relationship. In this level, people have no real interest in others and live with themselves. If a person is recognized, he or she is not accepted as a individual person but may be seen as extension of the “I.” The needs of others simply do not exist, nor does the responsibility of ethical behavior toward them. Buber’s next level is the “I–IT” relationship. In this case, people acknowledge that there are others, but they do not choose to have meaningful relationships with them. Because people are “Its,” they can be used as tools for personal benefit or the benefit of one’s organization. For Buber, I–IT relationships are morally wrong because they failed to accept people as having individuality and value. People serve only as a means to an end. Examples of I–IT relationships and their lack of respect for others and dialogue occur when administrators use the term “my people” or “my worker bees” to refer to their staff members. Another example happens when one refers to a patient as “the colon in 405” instead of by his/her name. Scott et al. (2009) discussed the need for I–IT relationships. For example, these relationships allow people to objectively study nature and medicine. However, they also acknowledge the danger of emphasizing these relationships because they limit the ability to estab- lish relationships with others. Kramer and Gawick (2003) also include US–THEM relationships in their appli- cation of Buber’s theory. This of relationship coordinates well with the I–IT viewpoint. For example, the US–THEM relationship allows people to be categorized into in the right or in the wrong. This division makes society easier to understand because people can be grouped as “us” or “not us.” People who are in the “us” believe themselves to be superior and avoid dialogue with those in the “not us” category. In addition, it easier to attribute negative events or actions to those who are “not us.” The I–YOU relationship has two categories and begins with the ability to recognize individuals as having value and unique talents, gifts, and ideas. These differences are not only recognized, but also accepted and respected. I–YOU Personal Ethical Theories 19 relationships also include genuine concern, affection, and interaction with others. An example of this type of relationship can be found in a well-functioning health- care team in which each member respects the contributions of the others. In this relationship, staff members not only recognize the individuality of their peers, but they also engage in respectful dialogue and attentive communication with each other. In addition, staff members expect and appreciate ethical relationships with their supervisors and with one another. When such an environment exists, they are more productive and exhibit higher morale. When working with patients, healthcare professionals also need to communicate using an I–YOU relationship. This ability to have a dialog with patients and understand them as individuals contributes to acquiring essential information to provide accurate diagnoses and enhance healing. The second category of I–YOU relationships is a relationship called “I–THOU,” which Buber viewed as the most the mature human relationship. In I–THOU, one recognizes each person as being different, having value and chooses to make the per- son beloved. This choice requires acceptance, being open to the other, compassion, and true dialogue while making one’s beloved’s needs equal to one’s own. Because of the commitment that it requires, it is not possible to have an I–THOU relationship with every person whom one meets. However, when a healthcare professional is treating a patient, the patient expects to be the most important person during that encounter. When sick, in , and frightened, they trust the healthcare profession- al’s ability to care. They also want the same level of patience and understanding that professionals would give to the beloved persons in their lives. Patients assume that these health professionals value their needs because they chose to have a career in a service-based industry. Likewise, the community assumes that an administrator acts with the highest regard for their needs and serves as a good steward of their resources. Buber, a scholar in the Judaic traditions, also includes relationship to God as part of I–THOU (Buber, 2010). His discussion acknowledges that people may not have a connection to organized religion, but also are able to recognize what he calls the “eternal thou.” He stresses the relationship that one can have with God and its connection to a sense of community and quality of life.

Theory Applications This short summary offers only the basics of Buber’s complex thinking and how it can relate to ethical behavior. However, I–THOU behaviors are often the difference between a patient-centered facility recognized for its excellence and one that is a - mare for staff and patients. Healthcare administrators should value I-­relationships as a requirement for success in their organizations. In addition, administrators must consider the quality of their own relation- ships with their staff and others. For example, when planning a new venture or evaluating a current program, are employees tools to get the job done as people who can contribute through their talents? Should administrators have I–YOU rela- tionships with their staff? Finally, if administrators were patients in their facilities, would they want to be treated with an I–THOU relationship? Would they want the community that they serve to think that their needs are important? These questions help understand how Buber’s thinking relates to the practice of ethical relationships in health care. 20 Chapter 1 Practical Theory

Smith et al. (2009) applied Buber’s work to healing relationships in health care. They defined healing to include valuing and being present with patients as a reflec- tion of Buber’s theory. Other processes included in the model were continuity of relationships, awareness, and managing one’s emotions. This model encouraged the I–THOU relationship with patients in place of the traditional I–IT relationship and stressed the role of clinicians as healers.

Lawrence Kohlberg (1927–1987) Biographical Influences on His Theory In 1945, joined the Merchant Marines and was actively engaged in smuggling Jews through the British blockade for settlement in . Arrested by the British, he served time in an internment in Cyprus. Because of this experience, he began thinking about how people develop moral reasoning and how ethical thinking is learned. When Kohlberg returned to the United States, he attended the , where he completed his ’s degree as well as a . Kohlberg was a professor in the University of Chicago and Harvard University. Kohlberg, influenced by the work of Piaget, studied the moral development of children. He used qualitative study methods to determine responses to a moral dilemma that he created. Kohlberg evaluated the level of moral development based on his subjects’ answers and the reasoning behind those answers. Based on this research, he devel- oped a hierarchy of moral development, which has been verified through additional studies in the United States and throughout the world. Kohlberg became an international name in the study of morality and ethics, but his death was a great . Toward the end of his life, Kohlberg suffered from pain and depression because of a parasitic infection that he contracted on a research trip to Belize. One January day in 1987, he parked his car on a dead-end street in Winthrop, Massachusetts, left his wallet and his keys in it, and walked into the freezing waters of Boston Harbor. The police found his body in a tidal marsh (Doorey, 2016).

Concept Summary How does a person learn moral judgment? To understand this question, Kohlberg worked on a developmental theory based on his research and the influence of Piaget (Kohlberg, 1984). With respect to understanding morals, individuals learn in stages and must understand one stage before they can to a higher stage. Progress in the stages happens when individuals face challenges and attempt to find solutions for those challenges. Solving these issues helps individuals advance in their moral development and moral reasoning. In addition, Kohlberg believed that people could not understand moral reasoning that was too distant from their own level of reasoning. In addition, he found that only about 25% of people ever get to the highest level of moral development and that most people remain on what he called Level IV. What are Kohlberg’s levels and stages of moral development? There are two stages in Level I or Preconventional Level. These stages are called premoral or Personal Ethical Theories 21 preconventional because they exist before a person has an inner sense of moral decision making. Their moral decisions are controlled by the influences of others. In Stage 1, people make decisions purely to avoid being punished or because they are told what to do by a higher . Decisions are based on consequences to themselves rather than higher-level reasoning. Stage 2 is centered on the personal outcome of actions. In this case, decisions are made based on selfish concerns and the ability to gain approval and personal reward. This is sometimes called the “What’s in it for me?” orientation to ethical decision making. In this stage, people are valued for their usefulness to the indi- vidual. Generally, behaviors in stages 1 and 2 are common in young children, but they are also present in adults. An example of this behavior occurs when individuals choose to act in ways that conform with social rules only if it benefits them. Kohlberg’s Level II, conventional or external-controlled moral development, includes Stages 3 and 4. Level II moves the person beyond self-interest to working well with others and maintaining some level of order (Kohlberg, 1984). For exam- ple, in Stage 3, moral decisions are made based on the need to please people and be seen as a good person. Thus, the motivation for ethical decisions relates to avoiding and . In the healthcare situation, employees take ethical decisions so that others see them as good employees, good parents, or good friends. They also want to avoid the stigma of being a “bad employee.” In Stage 4, moral decisions are made to comply with society’s need for law and order. Authority is usually not questioned; if it is the law, then it must be right. While it is necessary to respect rules and in a , there can be extremes. Extreme behavior in this stage explains how Nazi soldiers could con- duct the Holocaust and still consider themselves to be moral people: they simply claimed that they were being good soldiers, obeying the law and its fullest extent (Kohlberg, 1984). Level III in Kohlberg’s model is called the principled or postconventional level. This title is used because individuals move beyond the need to please individuals or the standards of society. They are choosing to apply higher or more universal moral principles (Kohlberg, 1984). In Stage 5, ethical decisions are based on a set of rights and responsibilities that are common to all members of a group or community. Moral decisions are based on respect for oneself and the rights of others. This stage requires complex thinking about one has with others and not just about legal responsibilities (Kohlberg, 1984). For example, when a government or group makes decisions about the use of healthcare resources, they must use complex moral reasoning. Therefore, an element of Stage 5 reasoning should be present. The basis for Kohlberg’s Stage 6 moral reasoning is created by universal prin- ciples of ethics. These principles are higher than the authority of law and include ideas of justice and respect for persons and their rights. In this stage, decisions are made based on higher-level principles that exceed legal compliance. In addition, those who are functioning at Stage 6 believe that all humans have worth and value regardless of their societal status (Kohlberg, 1984). For example, Stage 6 ethical thinking was involved in the decisions made by King, Jr., and others in opposing segregation. While segregation was legal, it certainly did not comply with Stage 6’s position on morality. People who understood the difference and func- tioned on a Stage 6 level used to bring attention to this issue and create change. 22 Chapter 1 Practical Theory

Theory Applications For healthcare administrators and professionals, Kohlberg’s theory of moral reason- ing provides an understanding of moral decision making. As a health administra- tor, is important to understand the ethical reasoning that is needed in healthcare so that appropriate decisions can be made. In addition, it is also useful to recognize that everyone does not use the same level of ethical reasoning when making decisions. Administrators also need to consider Kohlberg’s assumption that if there is too great a difference between one’s level of moral reasoning and others’ level, there may be a mis- understanding concerning decisions and their application. Understanding Kohlberg’s ideas can also help administrators analyze their own decisions and determine their own moral reasoning. This ability should prove useful in defending ethics decisions. An administrator should be able to answer questions such as “Why did you decide to act as you did?” and “What was your reasoning?” (Schissler Manning, 2003). There is also another implication of knowing and understanding Kohlberg’s theory—one involving patients and their relation to the healthcare system. Society gives the healthcare system a high level of authority with respect to autonomy and patient care. Along with this authority comes an assumption of trust. This means that patients have faith that administrators and providers are functioning at a high level (at least on Level IV) of moral reasoning when making decisions about their care and treatment. In other words, patients expect those who provide care to have the ability to put their needs first and the healthcare organization’s profit second. When of actions that profit is more important than patient care is uncovered, the public loses trust in the system. Once this trust is lost, it is difficult to regain and can have a negative impact on the future of healthcare organizations and the system.

Carol Gilligan (1936–Present) Biographical Influences on Her Theory Carol Gilligan is a psychologist who is known for work on girls’ and women’s devel- opment. She earned her PhD in at Harvard University and began teaching there in 1967. Gilligan became Lawrence Kohlberg’s research assistant in 1970. Initially, she agreed with his theory and principles of social research. However, as she became more involved in his process, she became concerned about the treatment of difference, the lack of female voice in the data, and the need to consider relationships in ethics decision-making (Gilligan, 1993). Her theory of ethical development, called the ethics of care, has become part of the discussion on applying ethics nursing and other professions and is considered part of virtue ethics. This “potential moral theory” (Held, 2006, p. 9) supports future thinking about feminist response to ethics and the importance of relationships in ethical decision-making.

Concept Summary The ethics of care model was based initially on Gilligan’s research and replication of Kohlberg’s studies using both male and female subjects. Her research indicated that when the same Kohlberg scenario was presented to male and female subjects, there were differences in the responses and thinking. She showed that girls showed Summary 23 a different of moral development that included thinking about relationships and caring for others (Gilligan, 1993). Perhaps, she concluded, there was a “‘different voice’ in the way many girls and women interpret, reflect on, and speak about moral problems” (Held, 2006, p. 27). Gilligan (1993) found that Kohlberg’s preconventional, conventional, and post- conventional levels were different for women. For example, in the preconventional level, emphasis was on caring about the self rather than others. However, individuals can transition to understand that needs can be connections between themselves and others. This leads to the conventional level, where relationships of responsibility and caring for others become important. Finally, in the postconventional stage, there was a need to balance caring for self and for others. Gilligan’s research also led to an examination of biases about the moral nature of women. For example, male traits such as autonomy and intellect are valued more than feminine traits such as connections and sharing. In addition, male processes for moral reasoning appeared to be more valued than those of females. Gilligan’s work also inspired many other writers to explore the ethics of care, virtue ethics (Darr, 2011), character traits of nursing, and the ethics of care model (Volker, 2003; Lachman, 2012). Given the relatively new nature of this expanding theory of eth- ics, there have also been with respect to research methodology, number of replication studies, and vagueness of application (Herd, 2006). However, this approach appeals to the nursing profession and others who provide patient care. Therefore, research will continue to refine this theory and its practice.

Theory Applications While the ethics of care theory is relatively new, it appears to have merit when applied to the practice of health care. For example, in an article by Lachman (2012), the use of the theory applied to nursing practice. For example, nurses should be attentive to their patients needs, assume responsibility for patient care, and maintain their professional competence. In addition, they should understand that patients are vulnerable and their actions should be respectful and reciprocal. Lachman con- cluded her comments by stressing that “when a person chooses to be a nurse, he or she has made a moral commitment to care for all patients. Such a decision to care is not taken lightly…” (Lachman, 2012, p. 114). Purtilo and Doherty (2011, p. 77) also support this position by asking “what is required of a health professional to be best able to express, ‘I care’?”

▸▸ Summary The theories discussed in this chapter form the foundation for the chapters that follow in this book. They form the basis for principles of ethics that are the focus of discussion in the next three chapters in this section. However, the theory of ethics goes beyond the chapters in this book. Understanding how to apply them can assist healthcare administrators in making decisions that balance fiscal responsibility with appropriate patient care. Given the nature of health care, the ability to apply theory to practice will enhance healthcare administrators’ value to the institutions that they serve and their personal reputation as ethics-based administrators. 24 Chapter 1 Practical Theory

A CASE FOR ETHICS

Case Information The following cases are part of a series that features three administrators and their private discussions related to ethics. Consider the ethics theories that would apply to these conversations. Note that while theories are discussed, other theorists could also support the administrators’ comments. The Leona Grant Case Three administrators from Franklin Family Clinic meet for coffee after their annual meeting. Jo begins the discussion by saying, “How about that Leona Grant for $60,000? This money can help our clinic meet its mission.” Sam adds, “Yeah, it can. I think that we should expand our children’s immunization program so that there is greatest benefit for the greatest number of children in our service area.” Then Michaela says, “I think we should spend it on training our staff for patient-centered care and cultural competency. After all, we have a duty to treat all of our patients with respect, but I am not convinced that our staff is doing their best in this area.” Finally, Jo says, “We should add more funding to our noninsured reserve fund. Anyone could be in a place where he/she cannot afford care when it is needed. Keeping them healthy also keeps us healthy.”

Commentary on the Case In the Leona Grant Case, Sam’s comments demonstrate Mills’ ideas about providing the greatest good for the greatest number and preventing the greatest harm for the greatest number. Providing immunizations to children would not only protect those with the immunizations but also reduce the incidence of disease so that more children are protected. Michaela’s comments about duty apply theory. Of course, deeper thinking may apply other theorists, which would suggest that there are many ways to apply ethics to decision-making. The Trip to Florida Case Three administrators from Franklin Family Clinic meet for coffee after work. Michaela says, “You won’t believe what happened to me. Our drug rep offered me a full week’s vacation package to Orlando and Universal Studio. You know how much I love Harry Potter.” Sam responds, “Wow! That sounds so tempting. If I were you, I would do some thinking about how much I want to go and what might happen if somebody found out. You need some wisdom here to make the best decision.” Jo joins the conversation by saying, “I wonder why he would make this offer. He is probably just trying to guarantee your business and the trip is a bribe. He can use you for his benefit and it is not really about how much he values you as a person.” Michaela responds to her friends and says, “I admit that I was tempted to say ‘yes’, but then I remembered our policy about accepting gifts from vendors. It would not be right for me to have this trip when I did not earn it. No one else was offered this opportunity.”

Commentary on the Case The Case of the Trip to Florida also features theorists that you encountered in this chapter. Sam’s comments about needing wisdom to decide what the best solution would be an application of Aristotle’s concept of practical wisdom. Jo’s comments might suggest the influence of Kohlberg’s levels of moral development. Of course, as previously mentioned, other theorists can also apply. The point of the analysis is to think about how theory connects to actual situations in health care. References 25

▸▸ Web Resources The Stanford Encyclopedia of Philosophy is a well-researched source for additional information about the theorists in this chapter. Here are the links to their materials. Sites for theorists not mentioned in that resource are also included here. St. Thomas Aquinas, http://plato.stanford.edu/entries/aquinas/ Martin Buber, http://plato.stanford.edu/entries/buber/ Carol Gilligan, https://plato.stanford.edu/entries/feminism-ethics/ Immanuel Kant, http://plato.stanford.edu/entries/kant/ Lawrence Kohlberg, https://plato.stanford.edu/entries/childhood/ John Stuart Mill, http://plato.stanford.edu/entries/mill/ John Rawls, http://plato.stanford.edu/entries/rawls/

References Ashcroft, R. E., Dawson, A., Draper, H., & McMillan, J. R. (2007). Principles of health care ethics. West Sussex, UK: John Wiley & Sons. Beauchamp, T. L., & Childress, J. F. (2013). Principles of biomedical ethics (7th ed.). New York, NY: . Blackburn, S. (2001). Ethics: A very short introduction. New York, NY: Oxford University Press. Brown, C. M. (2018). St Thomas Aquinas (1224/6–1274). In The internet encyclopedia of philosophy. Retrieved from http://www.iep.utm.edu/ Buber, M. (2010). I and thou. Mansfield Centre, CT: Martino Publishing Darr, K. (2011). Ethics in health services management (5th ed.). Baltimore, MD: Health Professions Press. Doorey, M. (2016). Lawrence Kohlberg. Encyclopedia Britannica. Retrieved from http://www .Britannica/com/biography/Lawrence Kohlberg Gilligan, C. (1993). In a different voice. Cambridge, MA: . Held, V. (2006). The ethics of care: Personal, political, and global. New York, NY: Oxford University Press. Kerr, F. (2009). Thomas Aquinas: A very short introduction. New York, NY: Oxford University Press. Kohlberg, L. (1984). The philosophy of moral development: Moral stages and the idea of justice. New York, NY: HarperCollins. Kramer, K. P., & Gawick, M. (2003). Martin Buber’s I and thou: Practicing living dialogue. Mahwah, NJ: Paulist Press. Kraut, R. (2017). Aristotle ethics. In E. N. Zalta (Ed.), Stanford encyclopedia of philosophy (Summer 2017 ed.). Retrieved from https://plato.stanford.edu/archives/sum2017/entries/aristotle ethics/ Lachman, V. D. (2012). Applying the ethics of care to your nursing practice. MEDSURG Nursing, 21(2), 112–116. Macleod, K. (2017). John Stuart Mill. In E. N. Zalta (Ed.), Stanford encyclopedia of philosophy (Spring 2017 ed.). Retrieved from https://plato.stanford.edu/archives/spr2017/entries/mill/ 26 Chapter 1 Practical Theory

McInterny, R., & O’Callaghan, J. (2016, Winter). St. Thomas Aquinas. In E. N. Zalta (Ed.), Stanford encyclopedia of philosophy (2016 ed.). Retrieved from https://plato.stanford.edu/archives/win 2016/entries/aquinas/ Palmer, D. (2010). Looking at philosophy: The unbearable heaviness of philosophy made lighter (5th ed.). New York, NY: McGraw-Hill. Purtilo, R. B., & Doherty, R. F. (2011). Ethical in the health professions (5th ed.). St. Louis, MO: Elsevier. Rawls, J. (1999). A theory of justice (Rev.ed.). Cambridge, MA: Harvard University Press. Rohlf, M. (2016, Spring). Immanuel Kant. In E. N. Zalta (Ed.), Stanford encyclopedia of philosophy (2016 ed.). Retrieved from https://plato.stanford.edu/archieves/spr2016/entries/kant/ Rohlf, M. (2017, Summer). Aristotle ethics. In E. N. Zalta (Ed.), Stanford encyclopedia of philosophy (2017 ed.). Retrieved from https://plato.stanford.edu/archieves/sum2017/entries /Aristotle-ethics/ Schissler Manning, S. (2003). Ethical leadership in human services: A multi-dimensional approach. Boston, MA: Pearson Education. Scott, J. G., Scott, R. G., Miller, W. L., Stange, K. C., & Crabtree, B. S. (2009). Healing relationships and the existential philosophy of Martin Buber. Philosophy, Ethics, and in Medicine, 4(11), 1–9. Summers, J. (2019). Theory of healthcare ethics. In E. E. Morrison & B. Furlong (Eds.), Health care ethics: Critical issues for the 21st century (4th ed., pp. 3–46). Burlington, MA: Jones & Bartlett Learning. Vaughn, L. (2010). : Principles, issues, and cases. New York, NY: Oxford University Press. Walsh, C. (2000). The life and legacy of Lawrence Kohlberg. Society, 37(2), 36–41. Wenar, L. (2017a, Spring). John Rawls. In E. N. Zalta (Ed.), Stanford encyclopedia of philosophy (2017 ed.). Retrieved from http://plato.stanford.edu/archives/spr2017/entries/rawls/ Wenar, L. (2017b, Winter). In E. N. Zalta (ed.), Stanford encyclopedia of philosophy (2014 ed.). Retrieved from http://plato.stanford.edu/archives/win2014/entries/buber/ Wilson, F. (2007). In John Stuart Mill, Stanford encyclopedia of philosophy (pp. 1–62). Retrieved from http://plato.stanford.edu/archives/entries/mill/ Zank, M., & Braiteman, Z. (2014). Martin Buber, Stanford encyclopedia of philosophy. Retrieved from https://plato.stanford.edu/entries/buber