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Dr. Peter DePergola (drpeterdepergola@gmail.com) is Founder and Chief Executive Officer of V.I.P. Bioethics and Director of Clinical Ethics at Baystate Health in Springfield, MA. He is also Assistant Professor of Medicine at University of Massachusetts Medical School in Worcester, MA, and Assistant Professor of Medical Humanities at the College of Our Lady of the Elms in Chicopee, MA.
Recent upheavals in healthcare distribution in the United States have underscored numerous conflicts that exist between traditional business goals and the ends of established and traditional professions. As a result, healthcare workers inescapably find themselves acting in dual roles: on the one hand, as clinical professionals dedicated to the care of individual patients; on the other, as employees of healthcare businesses, some of which aim, and all of which (to some extent) do, profit from the aforementioned exchange between provider and patient.
Hence, clashes between competing obligations in healthcare are prominent, and the result has transformed medicine into one of the most controversial “businesses” of the contemporary age.Tensions, frustrations, and conflicts within and between individuals who struggle to carry out traditional obligations have demanded an ethics that confronts the problem of maintaining professional integrity in the absence of traditional autonomy.
Such an organizational ethics aims to develop and evaluate the organizational mission of a particular system, to create and subsequently foster positive ethical climates within the organization that support and forward its mission, to develop comprehensive decision-making models for ensuring such support as reflected in activities within the organization, and to serve as a moral advocate, evaluator, and arbiter of organizational and professional behavior.
In the context of healthcare, organizational ethics, in its simplest form, serves to articulate, apply, and evaluate the coherent and consistent values and moral stances of the healthcare organization by which it is defined. In the effort to secure transparency, dignity, and propriety, organizational ethics in healthcare necessarily consists of processes to address ethical issues associated with business, economic, and administrative areas of healthcare organizations, as well as with clinical, professional, educational, and contractual relationships that affect the general operation of the organization as a whole.In this way, serving as the individual health system’s moral compass, organizational ethics informs the mission, vision, and values of its clinical and professional practice.
Organizational ethics in healthcare
Organizational ethics is a relatively new moral enterprise. As mentioned above, organizational ethics, at its core, can be understood as the articulation, application, and evaluation of the values and moral stances of the organization by which it is defined.This effort serves to secure transparency, dignity, and propriety within the organization, and consists of processes to address ethical issues associated with business, economic, and administrative areas, as well as with professional, educational, and contractual relationships that affect the general operation of organization as a whole.
The moral climates within individual organizations therefore consist of shared understandings of the broad and ubiquitous characteristics of a system that affects a broad range of critical decisions. Such climates define the organization through its internal and external relationships. Organizational ethics are also articulated in both value and mission statements of individual systems, organization codes of ethics, policies delineating ethical issues and the protocol with which they correspond, and through the fostering of attitudes and activities that are representative of the organization as a whole. Hence, organizational ethics focuses on the ethical dimensions of “midlevel phenomena.”This includes the motives, the nature and quality of the actions, and the effects such actions have on individual organizations.
The primary moral agent in organizational moral matters is the organization itself, which is neither an individual entity nor a complete social system. Precisely as an organizational system, it is a subunit of a larger society that is composed of individual persons who play various roles, and is authorized and supported by society to function for specific purposes. As such, the organizational ethics of individual systems are oriented toward the society of which it is a component, toward other organizations, institutions, and corporations with which it is interrelated, and, finally, toward individuals — both those who serve the organization and those whom the organization serves.
Hence, although organizations are not “individuals” in the strict sense, and are not, therefore, moral “persons,” they still act as moral agents by:
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setting goals which are specified explicitly in their respective codes of ethics;
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deliberating and thereby “acting” in the process of decision making;
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being normatively evaluated by other organizations with which they interact; and
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being held accountable on all poles of normative evaluation — as agents, on the nature of actions in question, and by the effects of such actions.
If organizational ethics is a relatively new moral enterprise, organizational ethics in healthcare is one newer still. In 1995, The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) added a section on “Organizational Ethics” to its accreditation standards for all healthcare organizations. These standards focus the attention of individual health systems on a particular set of issues that had previously gone unaddressed by the typical regulatory tools in healthcare. According to the JCAHO standards, accredited healthcare organizations are those that have developed and instituted an organizational code of ethics that addresses a number of specific activities inherent to the individual healthcare system, including those pertaining to billing, patient transfer, marketing, and the like. Moreover, accredited healthcare organizations must explicitly address ethical issues in contractual obligations and professional relationships, both within the beyond the bounds of the individual health system. These standards aim to improve the quality of healthcare provided to the public through the application of “ethical guideposts” that guide business and govern the practice of healthcare while maintaining accountability to the communities served.
A robust organizational ethics that complies with JCAHO standards therefore addresses the challenges of how to prioritize and enforce limits in a manner that is clinically sound, ethically justifiable, and politically acceptable. As such, it strives to provide principled standards for distributive justice, and thereby serves as a moral beacon for related healthcare organizations. An exemplary organizational ethics in healthcare thus possesses a set of values that:
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emphasizes care of the sick and the promotion of health;
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involves essential stakeholders in the identification and management of its values, particularly in the event of conflict;
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transparently and forcefully states the values to which it commits and by which it guides itself; and
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cooperates and abets only with those who live by its values.
Other central ethical obligations include communicating the understanding of its values to its entire staff; recognizing that the entire scope of its practices critically influence patient care; fostering trained observation of potential and actual threats to and conflict among its core values; deliberating about conflicts of value in light of how similar events were resolved in the past; and ensuring that it acts on its values through intentional behavior.
Organizational ethics in healthcare acts as the heart of the individual health system, circulating blood that oxygenates the entire organization with a common purpose and a set of shared values that foster commitment.In absence of such a strong organizational ethics, healthcare cannot escape confusing the market as the source of its value and as the arbiter of its conflicts.
