Organizational Ethics In Health CareAn Overview

Philip Boyle, Ph.D.Vice President, Mission & Ethics

www.CHE.ORG/ETHICS

What is organizational ethics?What is unique to OE?The nature of organizations—their ecologyHow to study organizations? What is unique about • organizations?• healthcare organizations?• RC organizations?

Definitions Applied ethics family resemblances • Business ethics• Management ethics• Corporate Ethics• Institutional Ethics• Organizational Ethics

Definitions• Nash: “The study of how personal moral norms

apply to the activities and goals of a commercial enterprise. It is not a separate moral standard, but the study of how the business context poses its own unique problems for the morals person who acts as agent of the system.”

• Boyle, et al. Focus on the choices of all individuals in an organization and on the choices of the organization as organization in bring fulfillment to individuals and the community

Definition

• OE evaluates of moral choices of individuals and the organization itself in pursuit of the organization’s mission.

• OE focuses on organizations as moral agents.

• OE also examines decision-makers inside and outside the organization

Moral agency of institutions

• Are we drinking the cool aid?

• In what ways are organizations moral actors?

Moral agency of institutions• Philosophers—it is not a moral agent

• Theologians—it is a moral agent

• Mediators—it acts as IF it were a moral agent; helpful analogy

Moral Agency of Organizations

• Legal– 19th century property– 1978 Pinto criminal behavior– 1978 Corporation have free speech rights– 1991 Sentencing guidelines– 2010 Citizens Untied v. Fed Elction

Commission

Moral Agency of Organizations • Sociology—plain language

– Organizations exist after an individual dies

– Said to hire and fire

– Said to pursue missions that override the mission of any individual

– Its actions are not reducible to actions of employees

Moral Agency of Organizations Moral• Held accountable• Praised and Blamed• Decision making—not on impulse• Acts in rational ways--policies• Creates culture

Case of Len• 35-yr-old level 3 sex offender• Drunk & raped minor at age 19• Enters St. Dymphna Clinic after + drug screen• Alerts local division of justice per Megan’s law• Police alert schools and they inform families• Discuss

– What’s the issue?– Who is responsible?

Moral Ecology• Cell• Individuals• Groups• Regional Ecosystems• Ecosystem• Biosphere

• Individual acts• Moral agents• Departments• Institutions• Organizations• Healthcare system

Moral Ecology Advantages• Honesty--clear about

perspective• Which level is more

important?

Disadvantages• Other levels obscured• Can obscure

differences between organizations

The Actors & Risks• Sponsors—clear role• Boards--clear process• Managers

– Senior management—discretion– Middle

• Finance—conflicts of interest• HR—hiring firing, promotion• Marketing—truth in advertising• Development—nature of gift acceptance• Environmental services—safety• IS--confidentilaity

The Actors & Risks• Employees—common risks of agent-

principle relationships• Consumers/patients—participation &

appeal• Purchasers/vendors—nature of

cooperation

Range of issues

• Across all organizations– Discretion and control– Resource allocation– Conflicts of interest

• Organization specific– Home health v. acute

• Department specific– Finance v. development

How to study organizations? • Rational systems

– Formal—examines policies• Natural systems

– Informal—examines real practices• Open systems

– External systems—examines liability, laws, regulations, etc.

How to study Formal• Personnel arranged in a hierarchy of authority• Those in policy making higher positions are

regarded as professional managers• Most relations can be described as principle-

agent relationships• Division of labor with each position having

limited authorized actions• Following policies and procedures• Products are joint outputs

How to study Formal Risks• Joint output--mission substitution• Hierarchy --expert imperialism• Clear roles--dithering, stalling,

obstruction• Managerial expertise--incompetence

How to study Informal• Culture is the glue of the organization• Values and beliefs of all participants and includes the

internal and external interpretation of those beliefs• Informal unstated ways of acting• Difference between policy and actual practice• Moral psychology

– Wendy Carlton: In our Professional Opinion: – Charles Bosk: Forgive and Remember– Danial Kahneman and Amos Tversky Judgment under

Uncertainty: Heuristics and Biases; – Michael Davis: “The Challenger Disaster”– Jerome Groopman: How Doctors Think

Uniqueness of health care organizations

What distinguishes healthcare from others kinds of organizations?

• Opportunistic – rapidly changing• Any organizations that participates in

healthcare: Purchaser/Vendor/Provider• Industrialization process: use of industrial

techniques for predictable outcomes• Move from a medical professional to

managerial professional

Uniqueness of organizations

• What is unique about RC organizations?

– What is unique about RC education?

– What is unique about RC health care?• God is Love #31-33

Mechanisms to address OE

• Values based discernment process• Subcommittee of ethics committee• Ad hoc groups• Senior management team• Mission Effectiveness Committees

Conclusions• Moral agency of organizations• How to study

– Formal—policies– Informal—practice

• Overlap between clinical and organizational ethics

• Dig in with low hanging fruit• Different mechanisms