30 Organizational Ethics Spring 2005 Business Practices, Ethical Principles, and Professionalism Ann E. Mills and Mary V. Rorty INTRODUCTION tices did not require constant ethical reexami- nation because of the relative autonomy of the Whether in single practice, research orga- physician as professional, the radical restruc- nizations, government facilities, or complex turing of the healthcare system and the way hospitals or clinics, physicians practice in healthcare has come to be reimbursed in the organizations. They are influenced by, and last two decades has brought into greater sa- influence, the internal business practices of lience the impact of systemic business prac- the organizations with which they are affili- tices on professional practice. ated, as well as the business practices of other The Accreditation Council on Graduate organizations that are part of the delivery sys- Medical Education (ACGME) acknowledges in tem. It has always been true that the way in its standards the interrelation of profession- which care is delivered involves business alism and business practices.1 In the fifth and practices. Healthcare delivery, whatever the sixth competencies listed in the ACGME Out- model, is a business that involves costs and comes Project, ethical professional practice is reimbursement issues. If there was earlier placed in the context of the larger system some hope that professional business prac- within which the physician practices. If ethi- cal professional standards are reflected in ap- Ann E. Mills, Msc (Econ), MBA, is an Assistant Profes- propriate business practices, then the out- sor and Director of Outreach Programs in the Center for comes of the healthcare system as a whole may Biomedical Ethics at the University of Virginia in also be professionally responsible. But pro- Charlottesville, [email protected]. fessional goals and the business practices de- Mary Varney Rorty, PhD, is a Clinical Associate Profes- signed to achieve them are not necessarily sor in the Stanford Center for Biomedical Ethics in Stanford, correlated throughout a healthcare system. California, [email protected]. © 2005, University Pub- Individual professionals may not have enough lishing Group. control, either of the institutions in which they Volume 2, Number 1 Organizational Ethics 31 practice or in the healthcare system as a goals and outcomes, and how they are de- whole, to assure ethically appropriate results. signed in order to understand how threats to Furthermore, in any business practice, there professionalism may arise through them. are design characteristics that must be con- While business practices are a necessary con- sidered. If we want physicians to commit to dition for professional activity, they may be a standards that have been associated with pro- source of problems as well. The problems fessionalism, then the systems within which faced by an ethical individual within an un- they work, and the business practices that are ethical system are not new or unique to medi- designed to achieve the goals of those systems, cine, but they do call attention to the impro- must support their activities as professionals. priety of holding individuals responsible for This can be achieved only if we design sys- systemic failings. We conclude that enlarging tems that are responsive to professional val- the concept of professionalism to include ues and are characterized by some degree of greater consideration of cost will not be flexibility. Business practices are not static, enough for physicians and the organizations and the healthcare delivery system is frag- with which they are affiliated to achieve the mented. Each component, on each level—in- goals of the sixth competency. For this, we dividual physicians, healthcare organizations, may need to require that the system as a whole the payers and managed-care organizations to commit to the same goals. that interact with them—has a plurality of values and goals that are supported by their THE ACGME COMPETENCIES own business practices. The more responsi- bility that is entrusted to professionals, the The fifth competency provided by the ACGME greater the temptation may be for other com- invites this reexamination. It states: ponents of the delivery system to design in- Residents must demonstrate a commit- tersecting practices that may corrupt or be ment to carrying out professional respon- perceived as corrupting professionalism. sibilities, adherence to ethical principles, In this essay, we look at the fifth and sixth and sensitivity to a diverse patient popu- competencies of the ACGME, consider the lation. Residents are expected to: goals and values that they presuppose and the •demonstrate respect, compassion, and practices associated with them: the means by integrity; a responsiveness to the needs which organizations or individuals achieve of patients and society that supersedes their corporate or individual ends. We con- self-interest; accountability to patients, centrate on business practices, defined society, and the profession; and a com- broadly as relationships, processes, or proce- mitment to excellence and on-going dures designed to meet some goal or produce professional development some outcome. We demonstrate that each •demonstrate a commitment to ethical component of a business practice—its goal, principles pertaining to provision or the relationships or interactions which it en- withholding of clinical care, confiden- compasses, as well as the outcomes it pro- tiality of patient information, informed duces—should be scrutinized for the ethical consent, and business practices [au- principles on which it relies as well as its ef- thors’ italics] fects on the other components. We focus our •demonstrate sensitivity and respon- remarks at the organizational level of the de- siveness to patients’ culture, age, gen- livery system, but they can apply to the mi- der, and disabilities.2 cro-level of the individual practitioner, and to the macro-level of the objectives of the sys- The requirement of the ACGME that phy- tem as a whole. We address questions of what sicians “demonstrate a commitment to ethi- business practices are, how they are linked to cal principles pertaining to . business prac- 32 Organizational Ethics Spring 2005 tices” as a condition for professionalism is a nizes that physicians practice at every level demand that physicians run their practices or of the delivery system and that physicians are operate their clinics or perform research in a constrained to act as patients’ advocate within way that is consonant with their professional that system. Differences in requirements, pro- ethics, and that they resist practices that pre- cedures, regulations, or business practices in vent or distort their professional judgment. the organizations with which practitioners This competency calls for residents and other interact affect their ability to exercise their physicians to make a commitment to the ethi- professional judgment on behalf of their pa- cal principles that pertain to medical ethics, tients. clinical ethics, and “business practices.” It is In the sixth competency, the ACGME reit- a three-pronged approach that acknowledges erates the overarching professional goal and business practices are related to professional- desired outcome for physicians and whatever ism, and so may influence the way in which system within which they practice: to deliver care is delivered.3 care of optimal value. The fifth competency The sixth ACGME competency states: requires that professionalism include a com- Residents must demonstrate an awareness mitment to the ethical principles of business of and responsiveness to the larger con- practices, and the sixth competency supplies text and system of healthcare and the abil- the goal toward which those business prac- ity to effectively call on system resources tices are coordinated. to provide care that is of optimal value. Residents are expected to: WHAT ARE BUSINESS PRACTICES? •understand how their patient care and other professional practices affect Business practices are the way in which other healthcare professionals, the people, resources, and technology are brought healthcare organization, and the larger together to try and fulfill the values and goals society and how these elements of the of an organization. Interactions—relationships system affect their own practice or procedures, processes or systems, policies •know how types of medical practice or activities—can be examined as “business and delivery systems differ from one practices,” depending upon the context in another, including methods of control- which they occur and the role they play in ling healthcare costs and allocating the operations of an organization or physician resources practice.4 Business practices may be formal •practice cost-effective healthcare and or informal, simple or complex, but they ex- resource allocation that does not com- ist only to fulfill the organization’s goals. (An promise quality of care organization leader would be hard pressed to •advocate for quality patient care and justify any business practice that does not in assist patients in dealing with system some way fulfill a goal associated with the complexities organization.) They are designed and imple- •know how to partner with healthcare mented to produce desirable organizational managers and healthcare providers to outcomes by affecting the behavior and deci- assess, coordinate, and improve sion making of internal or external stakehold- healthcare and know how these activi-