SPECIAL SECTION TAKING ON ORGANIZATIONAL

stablished ethics committees are known to need to engage in a fairly extensive and intensive be a focus for addressing ethical issues in To Do So, period of self-education regarding organizational healthcare institutions and . ethics, just as it had to educate itself about medi­ It is natural, therefore, for to Ethics cal ethics. turn to the ethics committee for assistance Other committees mav find they can combine witEh organizational ethics. But, until now, most committees have focused almost exclusively on Committees clinical ethics. Unfortunately, the skills they have Summary Healthcare ethics committees, developed and the credibility they have estab­ which have focused almost entirely on clinical lished in addressing clinical ethics do not neces­ Must First ethics, now need to prepare to deal with organiza­ sarily carry over into organizational ethics. tional ethics, a field that is attracting increasing Although organizational ethics is attracting attention. increased attention in healthcare (partly because Prepare As they did with clinical ethics, ethics committee of the standards of the Joint Commission on members must educate themselves in the demands Accreditation of Healthcare Organizations), no Themselves of the newer field. As before, they must respect the one has a very clear understanding of what orga­ perspectives of the actual decision makers while nizational ethics is all about. As such understand­ maintaining an independent framework for analyz­ ing does evolve, some key decision makers may BY LEONARD J. ing the issues at stake. They must ensure that man­ well determine that the established ethics com­ WEBER, PhD agement is properly represented on the committee. mittee is not the best mechanism in their institu­ If they need guidance from a professional ethicist, tions for addressing organizational ethics issues. they should seek one with a strong background in On the other hand, it seems likely that other and social justice. ethics committees will be expected to take Healthcare organizations are likely to need help responsibility for organizational ethics. They with a wide range of ethical issues involving need to prepare themselves to do this work well. patient services (rationing of resources, for exam­ ple), business and service plans (mergers and joint PREPARING FOR ORGANIZATIONAL ETHICS ISSUES ventures, for example), business and professional An ethics committee might begin its preparation integrity (conflicts of interest, for example), employ­ by recalling how it got ready to handle issues in ee rights and responsibilities (downsizing, for clinical ethics. example), and the 's role in the com­ Self-Education For example, a committee may munity (advocacy and lobbying, for example). To be helpful to the organization, the ethics committee must be prepared to say when cost factors trump other considerations and when they do not. An ethics committee will often be asked to give advice on specific occasions—a proposed new poli­ cy, for instance. The most important part of its Dr. Weber is director, Ethics response is its analysis of the issue. Finally, an Institute, University of Detroit ethics committee should view its organization as Meity, Detroit. part of the larger social context.

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self-education with immediately accepting The committee cannot attend to ethical issues responsibility for a specific task (such as the adequately until it brings the right participants review or development of a particular policy); together. At the very minimum, the committee that is, they combine the task with a considerable must make sure there is sufficient (and the right amount of "homework." kind) of representation from management. Whether done in the context of addressing real Ethics Resource Person Many committees have issues or before accepting that kind of responsi­ found that access to a professional ethicist has bility, the committee's self-education is absolute­ been important in the committee's development. ly essential. An ethicist may help the committee educate its In dealing with clinical ethics, many commit­ members; he or she may help the committee tees have found that issue-based and case-based plan, develop, and participate in educational pro­ educational efforts are more effective than those grams for staff. In some cases, an ethicist may involving study of ethical theory. Committees serve as a continuing member of the committee. may therefore want to use a similar method in Ethicists can be valuable resources, perhaps espe­ educating themselves in organizational ethics. cially when the committee is developing its com­ Of course, case and issue study in organiza­ The best petence regarding new areas and issues. tional ethics involves much more than a sharing However, just as with committees, not every of personal opinions, just as it does in the study ethics ethicist competent to deal with clinical ethics is of clinical ethics. It requires familiarity with the equally competent to deal with organizational ethical concepts, with the generally accepted committees ethics. As will probably become clear in the dis­ guidelines, and, at times, with the legal consider­ cussion of issues below, the ethics resource per­ ations relevant to the case or issue. recognize the son for organizational ethics should have a strong Respect and Critical Distance To be credible, those background in business ethics and in social jus­ who advise others on practical ethical issues must tice. Some clinical ethicists have this background; maintain a delicate balance between two different experience of others do not. Like the good clinical ethicist, the virtues and skills. On one hand, they must respect good organizational ethicist should be able to the insights and perspectives of those who are on clinicians, but relate—in a practical manner—general ethical prin­ the front line and have to make the actual deci­ ciples, guidelines, and concepts to specific issues. sions. On the other hand, they must maintain do not always their own clear framework for analyzing the issues ISSUES IN ORGANIZATIONAL ETHICS at stake. In other words, the members of a credi­ agree with the In a general sense, being committed to "organi­ ble and effective ethics committee need to learn zational ethics" simply means bringing focused from the doers, but without losing their critical clinicians' ethical attention to the management of the distance. healthcare organization. "Business ethics," The best ethics committees are able to do this understanding "management ethics," and "corporate ethics" are in regard to clinical care: They recognize the expe­ all terms that have been used to describe the top­ rience and sensitivity of clinicians, but do not ics here discussed as issues in organizational always agree with the clinicians' understanding of of what is best ethics. what is best in policy or practice. In a similar man­ Healthcare organizations are likely to need ner, ethics committees are likely to acquire credi­ in policy or assistance with a wide range of these issues. bility in organizational ethics by respectfully Patient Services Issues of this type are related to engaging in dialogue with managers and, at the practice. admitting, admitting to special units, rationing of same time, developing for themselves a clear resources within the institution, billing, maintain­ rationale and framework for reflecting on the ing confidentiality of records, and other services organizational ethical issues. They need to respect and activities. the perspectives of managers without automatical­ Business and Service Plans These issues would ly agreeing with what managers propose. include managed care plans, plans for mergers Committee Membership Clinical professionals are in and joint ventures, marketing and advertising the majority on most ethics committees. This was strategies, plans for dealing with uncompensated done by design when the committees were care, and plans concerning the location of facili­ formed, and it made perfectly good sense when ties. most of the committee's work was related to clin­ Business and Professional Integrity Issues in this cate­ ical ethics. If, however, these same committees gory include resolving actual and potential con­ are now expected to address issues in organiza­ flicts of interest, employing financial incentives, tional ethics, they will need to review and revise setting criteria for performance review, and man­ their membership. aging bottom-line pressures, among others.

HEALTH PROGRESS MAY - JUNE 1997 • 21 SPECIAL SECTION

Employee Rights and Responsibilities Issues here diac dysfunction, and severe debilitation). include salary/wage scales, promotion opportu­ Otherwise, HOCM will be used. nity and criteria, collective bargaining, harass­ The proposed new policy is brought for review ment, workforce diversity, privacy, and downsiz­ to the ethics committee, where three particular ing. questions are raised: The Organization's Role in the Community These issues • Are we justified in using a more risky proce­ typically flow from, for instance, the organiza­ dure in order to save money or resources? tion's advocacy and lobbying activities, its invest­ • If we adopt the new policy, should we inform ment practices, its disposal of medical waste, and patients of it? its participation in community projects. • If we adopt this policy, must it be applied to An ethics committee that has been working everyone, or can we leave room for physician dis­ primarily on clinical issues may be well prepared cretion? to address some of these issues, too. For exam­ Case Two A case manager for home care requests ple, committee members are likely to have an assistance from the ethics committee. She has just informed understanding of confidentiality, at had a conversation with a patient for whom she is least as it applies to medical records. They may arranging home care. The patient, an elderly also be prepared to provide assistance in thinking An ethics European American, said he does not feel com­ through criteria for admission to speciality units fortable around black people and especially dis­ in the institution, or in helping to manage some committee likes the idea of having a black person in his conflict-of-interest situations. Nevertheless, many house. "I'm a strong believer in staying with your ethics committees are at present ill prepared to must be own kind," said the patient. "Besides, I have a address some of the issues listed. right to decide who comes into the privacy of my Many committees are reluctant to deal with the prepared to own home." economic side of ethical issues. Most managers, The case manager needs to decide whether, on on the other hand, recognize that cost considera­ offer guidance one hand, to send the patient only white care­ tions always need to be taken into account—that givers, or, on the other, to tell the patient that it is indeed ethically irresponsible not to. the home care providers will not comply with his Managers also know that the financial soundness on the question request. She asks the ethics committee for help of the organization is not the only ethical value with her decision. She would like advice not only involved in most decisions. It is not always easy, of when cost on this case, but also on others like it. With the however, for organizational leaders to know committee's guidance, she intends to establish exactly when noneconomic values should over­ factors trump and publicize a clear policy. ride responsibilities related to cost. Case Three A task force has been appointed by the If an ethics committee is to be truly helpful to other hospital CEO to make recommendations regard­ the organization, it must be prepared to offer ing a reduction in the workforce. The task force is guidance on the question of when cost factors considerations asked to make recommendations about, first, the trump other considerations and when they do criteria to be used in deciding which employees not. should be laid off and, second, the process to be and when they used in implementing those decisions. One task SOME CASES IN ORGANIZATIONAL ETHICS force member is a senior-level manager who sees One way to identify types of organizational ethics do not. the whole question of downsizing as filled with issues is to make a list like the one above. Another ethical dilemmas. He persuades the other mem­ way is to cite specific issues that have been bers to ask the ethics committee for assistance in brought to the "ethics people" in various health­ thinking through one particular issue the task care organizations. The following are examples of force is considering: whether employees who the latter. have been selected for layoff should be (a) asked Case One The radiology department has been to depart immediately after they are informed of asked to change its policy regarding the use of the decision, or (b) given a week or two. high-osmolality contrast media (HOCM) and The task force member believes the organiza­ low-osmolality contrast media (LOCM). HOCM tion should make this decision quickly and confi­ causes more adverse reactions, but it is much less dentially. He asks the chairperson of the ethics expensive than LOCM. committee to schedule a meeting immediately to It has been proposed that the department use address this question. LOCM only in cases entailing particular risks Case Four An employee in health information (such as a history of adverse reactions to contrast management (HIM) asks the ethics committee to media, a history of asthma or allergy, known car- address the following issue at its next meeting.

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To obtain maximum reimbursement, the hos­ istics unrelated to performance—race, for exam­ pital has hired a consulting firm to provide a ple—in assigning employees to ? It would DRG education and optimization program. The probably prove helpful for the ethics committee firm is very aggressive in coding tactics. Indeed, to suggest ways the issue has been addressed in some of its "upcoding" recommendations would business ethics. It is not enough for members of seem questionable to HIM professionals. What ethics committees to be sensitive and open. They should the HIM staff do about these recommen­ need to have an informed understanding of the dations? And what, if anything, should they say issue under consideration. about them to hospital management? Case Three Once healthcare organizations begin to routinely seek ethics guidance on management RESPONDING TO REQUESTS FOR ASSISTANCE decisions, they will surely raise a number of As the examples above illustrate, it is often a spe­ employee-related issues. This is to be expected cific occasion (a proposed new policy, for because employee-related issues often have to do instance) that causes someone to ask the ethics with questions of fairness. committee for help in deciding what to do in a The specific issue raised here —whether particular situation. To be useful, the committee employees who have been laid off should imme­ should, first of all, help clarify the matters at stake. diately be sent away from the workplace—is likely In many cases, the committee should go further, to bring management different advice from dif­ giving its reasons for recommending one course ferent sources. If an ethics committee is asked to of action rather than another. The committee The most provide assistance in such a case, it should base its should explain its thinking, because only then can analysis on an informed understanding of the those who sought its advice make an informed important part nature and extent of an employer's ethical decision to accept or reject the recommendation. responsibilities to employees. The most important part of an ethics commit­ of an ethics Case Four When is a billing code misleading and tee's response to a request for help with an issue- when is it not? Is there ever justification for send is its analysis of the issue. If ethics committees are ing a misleading bill? If asked for advice, the going to respond effectively to requests like those committee's ethics committee might focus on the standards to above, they must first identify an appropriate be used in determining appropriate coding tac­ framework (or frameworks) for thinking ethically response to a tics. The committee might need to clarify what is about the issue. Perhaps I can slum what I mean at stake in using aggressive coding tactics: Who by adding a brief comment on each of the cases request for help might benefit from them? Who might be cited above. harmed? In this scenario, the committee may also need to offer some practical advice to staff who Case One The ethics of rationing provides a useful with an issue is appear to be caught between professional stan­ framework for analysis here. The proposed new dards, on one hand, and management expecta­ policy would ration an expensive medical its analysis of tions, on the other. resource (LOCM) precisely because of its cost. If there were no significant cost differential between the issue. In each of these cases, an ethics committee the two contrast media, few radiology depart­ should take what might be called a "social ments would hesitate to use LOCM routinely. responsibility" approach to the issues involved. It The question thus becomes one of just and fair should, that is, view the organization as part of rationing. the larger social context. The committee should There has been significant discussion about avoid acting as though only the organization's medical rationing over the years, some of which internal functioning were at stake. may be familiar to ethics committee members. At the heart of this On the basis of this familiarity, a good ethics approach is the belief that the ultimate responsi­ committee should be able to clarify the concerns bility of the healthcare organization is to serve the that need to be involved in any decision to with­ community. The organization's commitment to hold, for cost reasons, a medical procedure that is the community good should take priority over better than a less expensive one. This clarification even its own need to function smoothly. This could be very helpful to those who have to make approach is distinctive of not-for-profit organiza­ the actual decision. tional ethics. As ethics committees prepare them­ Case Two This case requires a somew hat different selves to address issues in organizational ethics, framework of analysis. The issue here is w hethcr, they may need to make a special effort to grasp or when, the institution should allow patient the importance of this focus on the good of t he- preferences to determine work assignments. community. Should supervisors consider employee character- Continued on pajje 32

HEALTH PROGRESS MAY - JUNE 1997 • 23 ENSURING QUESTION OF VALUE ORGANIZATIONAL ETHICS Continued from page 26 Continued from page 23 Continued from page 31

and board have used the process fre­ quently. In some cases, for example in 1996 when the system was consid­ GETTING STARTED ering acquiring another hospital, the F^ttention The cases above involve real issues process has continued the decision; in that have been raised in actual health­ other cases the process has shown to ethics must be care settings. They are presented here that the system was heading in a consistently visible. to give readers a sense of the variety direction it did not want to go. of such issues, not to suggest that an ethics committee needs to be well "Major decisions are so often driv­ versed in them all at the start. No en by the financial numbers or rela­ committee is likely to be asked for tional issues," observed Bruce F. issues, business issues, institutional help with such a wide range of Buchanan, president and chief execu­ issues, and societal issues as well as issues—or not immediately, at least. tive officer of Mercy Health System medical issues. Every aspect of the As they did in their work in clinical Oklahoma. "This approach puts the institution's life is of ethical concern. ethics, committees dealing with orga­ situation in the context of our mis­ • Someone must be responsible for nizational ethics can take some time sion and how decisions will affect the the endeavor. This could be a trained to develop and evolve. broader purpose of our organiza­ ethicist or someone who has other tion." responsibilities but who also possess­ Although the cases cited here have been raised precisely as ethical issues, Shortly after St. Anthony's Medical es a knowledge of ethics. But the they have not been brought to ethics Center in St. Louis joined SMHS in responsibility for ethics should not be committees. It is an open question 1995, its leaders used the decision­ relegated solely to this individual. whether an ethics committee is the making process in connection with Ultimately it is the responsibility of most appropriate mechanism for plans to renovate its emergency everyone within the institution. addressing such issues. It is certainly department. "The process led us to • Attention to ethics must be con­ important that these issues be take a brand new look at the project, sistently visible. Mechanisms for addressed carefully as ethical issues. and ultimately to abandon everything addressing ethical issues include an And if the ethics committee is to that had been decided," said David ethics newsletter; periodic case con­ assist in the ethical analysis, it needs Scifert, St. Anthony's president. "We ferences in which clinical, business, to be prepared to do the well. If, are now rethinking our entire strate­ and organizational cases are consid­ on the other hand, some other com­ gy." Seifert noted that doctors, nurs­ ered; a "journal club" that meets to mittee or person is given the respon­ es, and other people who work in the discuss articles in ethics journals; a sibility, that committee or person also emergency department—not adminis­ noon-time lecture series that focuses needs a thorough preparation. In trators—used the process and con­ on ethical topics; and a day or half- either case, organizational issues cluded "we were planning something day dedicated to ethical topics. should receive the same careful ethi­ suited for the past, not the future." cal attention that many healthcare THE BOTTOM LINE organizations now routinely give to PART OF WHO WE ARE Ethics is essential to realizing the mis­ issues in clinical practice. SMHS leaders hope that, as use of sion, values, and philosophy of orga­ the corporate decision-making pro­ nizations that claim to be grounded One service an ethics committee cess permeates all system levels, it will in a faith tradition and a faith stance. can perform immediately is sponsor­ become an integrated, instinctive way Ethics goes a long way in helping ing educational sessions on organiza­ of approaching decision making. such organizations realize their dis­ tional ethics for its members and oth­ ers in the organization. This is an The corporate decision-making tinctiveness in every dimension of important service that can be per­ process is already part of the culture organizational life. It can make a pro­ formed without delay. at Mercy Health System Oklahoma, found difference in shaping the iden­ says Buchanan. "Over time, we are tity and the behavior of the organiza­ Some institutional ethics commit­ intuitively incorporating components tion and its members. tees arc no doubt capable of "doing" of the process into decision-making Is explicit and sustained attention organizational ethics well. But a com­ at all levels," he said. "And each time to ethics of any value? It is difficult to mittee that has devoted its attention we use it, the educational process imagine a time when it would be of almost exclusively to clinical ethics continues. We learn more about more value. So much of what faith- will acquire such competence only by effective decision-making and we based healthcare stands for is being devoting considerable time and ener­ learn more about ourselves." n challenged by what is going on in gy educating itself in this somewhat healthcare itself and in society. Faith- different area of ethical analysis, n based healthcare has an opportunity =&tT For more information, call Barbara lil^j For more information about the case W. Meyer at Sisters of Mercy Health System, to offer a different perspective and a studies cited in this article, log on to 314-965-6100. different way of doing things. • CHAOnline, at http://www.chausa.org.

32 • MAY - JUNE 1997 HEALTH PROGRESS