BY: ROBERTO DELL'ORO, STD
Dr. Dell'Oro is senior scholar and assistant research professor, Center
for Clinical Bioethics, Georgetown University Medical Center, Washington, DC.
We hear a good deal about integrity and compliance in
discussions of health care ethics today. Perhaps one should take a moment to
inquire what those words mean.
The Two Models
"Compliance," as I will use the word here, has to do with the objective
dimension of a person's (or organization's) relationship to rules
and regulations. The rules and regulations are externally imposed. "Integrity,"
on the other hand, refers to the subjective side of the relationship.
Integrity is a creature of the conscience. Whereas the phenomenon of compliance
belongs primarily to the realm of law, integrity brings the question squarely
back into the realm of ethics.
It may help us to explore what I call the adversarial and complementary
models of compliance and integrity.
The Adversarial Model Examining the distinction between compliance and
integrity can help us understand the difference between them. If we were to
rank them on a moral scale, we would have to say that integrity is better
than compliance. It is not altogether cheering to hear, for example, that a
particular health care organization has been found compliant with the relevant
rules and regulations. Those rules and regulations are, on one hand, evidence
of the organization's sensitivity to ethics and, on the other, an indication
of a troubling lack thereof.
Of course, distinguishing between integrity and compliance is not the same
as separating them completely. After all, the very decision to abide by the
rules is itself a moral decision and thus brings the legal realm into the moral
one. Making the distinction is important, however, because it reminds us that
the roots underlying moral integrity are deeper that those justifying a decision
to comply with the law.
The Complementary Model Integrity and compliance programs have proliferated
in today's economically stressed health care environment. Such programs
have two functions:
- They proclaim the organization's commitment to the highest standards
of morality
- They articulate the values upon which the organization wants its members,
customers, employees, and stakeholders to conduct business
Yet, although corporate spokespersons speak with increasing frequency about
"integrity" and "compliance," they do not necessarily mean
by them the same things that other people do. To understand the corporate meaning
of those words, one must know something about corporate reality. To understand
what "integrity" means to a corporation, one must understand (and
agree with) the capitalistic vision grounding the institution's purpose
and function. To a for-profit institution's leaders, that capitalistic
vision provides the ultimate criterion for judging the ethical correctness of
the institution's actions. Integrity and compliance, then, relate in a
complementary fashion to one another, as means to an end. From this perspective,
to do business with integrity is to comply with the institution's goals — thus
conforming to capitalistic values and principles that are essentially self-serving.
The morally significant difference between the adversarial and complementary
models of compliance and integrity is this: The adversarial model is open, aware
of a larger context, whereas the complementary model is self-contained. The
adversarial model involves the recognition and appropriation of values beyond
a particular organization. The complementary model involves values pertaining
only to the organization itself. Under the complementary model, an activity
can be said to possess integrity as long as it complies with the organization's
purpose. No other, larger criteria exist.
A Model for Health Care Institutions
Which model — the adversarial or the complementary — is more appropriate
for health care institutions? Of course, choosing one or the other is not just
a matter of semantic preference. It involves identifying the moral point of
reference in the practice of medicine and, ultimately, the moral substance we
decide to attach to health care.
For those who do not distinguish the delivery of health care from ordinary
commerce, integrity and compliance are complementary. An organization that behaves
so as to achieve a commercial purpose — that behaves efficiently, productively,
and profitably — has integrity. From this perspective, a health care organization's
integrity will depend, like that of any other commercial organization, on compliance
with the capitalistic vision of the marketplace and with the forces of commercial
culture.
Evidence suggests that the complementary model is becoming widespread. Many
health care institutions have missions betraying a notion of integrity that
is entirely a function of the maximization of profit. In such cases, integrity
simply means compliance with the organization's economic interests.
But there are two problems with this use of the notion of integrity. First,
it is based on values different from those that have traditionally driven medicine.
Second, it is contradictory. An organization using the complementary model will
often say that human well-being is its highest value; in fact, however,
it must behave as if its own economic well-being were primary. In making
service secondary to profit, the complementary model strips the notion of integrity
of its moral substance. At the same time, it exploits the very idea of integrity,
invoking it in a way that bespeaks moral seriousness and raises expectations
of a moral character.
Capitalism's Ambiguity
In a way, this is the ambiguity in which a capitalistic system normally functions.
Capitalism likes to describe its operations as value-neutral while, at the same
time, advertising the "goodness" of products offered for sale in the
commercial culture. "Beyond selling individual products, that culture is
selling a set of commercial values," writes Robert Kuttner. "The collective
message of all advertising is that material consumption will lead to happiness."1
As it concerns health care, the promise of the market is to increase competition
and to rationalize the system, but without necessarily altering the fundamentally
social/moral nature of the clinical exchange or undermining the professional
standards entailed. Still, many questions remain both in relation to the market's
ability to deliver what it promises and its willingness to preserve the intrinsic
morality of medicine. To the extent that the market does both, it shares in
the goodness of the end being pursued as a functional, and thus neutral, means.
However, critics from several schools of thought have long warned against the
subtle social and ideological implications of the market and capitalistic mechanisms
in general. The ideological spectrum represented by such critics is quite wide,
comprising _oth neo-Marxist philosophers of the so-called "Frankfurt School"
(e.g., Theodore Adorno, Max Horkheimer, and Jurgen Habermas) and the most recent
social encyclicals of the Catholic Church.2
This body of thought reminds us of the social tendencies inherent in market
philosophy — its tendencies, for example, to neutralize noneconomic values
such as compassion, empathy, care, and concern for the common good; to reduce
interpersonal relations to mechanistic exchange; and to replace the experience
of gratuitous spiritual and esthetic appreciation with an obsession with the
production of material goods.
In fact, economists themselves are becoming increasingly sensitive to both
the market's anthropological presuppositions and its social consequences.
They tell us that complete reliance on the market's presumed self-correcting
dynamics is dangerous. In such an atmosphere, two things tend to occur:
- Market organizations influence nonmarket ones, rather than the other way
around. Faced with competitive pressures, a faith-based, not-for-profit hospital
will, for example, start looking and behaving like its for-profit competitors.
- Market norms drive out nonmarket ones. As Kuttner puts it, "When everything
is for sale, the person who volunteers time, who helps a stranger, who agrees
to work for a modest wage out of commitment to the public good, who forgoes
an opportunity to free-ride, begins to feel like a sucker."3
To talk about "integrity" in the context of contemporary health care,
one must first deal with the semantics. For example, it may be uncritical (or,
even worse, manipulative) for an organization to use the word to imply a concern
for values beyond business considerations when, in fact, the organization subordinates
those extra-market values to its own economic interests. Using "integrity"
in its complementary sense could be regarded as essentially unethical. To avoid
that, we should examine the characteristics of integrity as a moral category.
Here I will look, in particular, at the moral challenges posed by medicine's
increasing commodification to both health care institutions and health care
professionals. Finally, I will articulate the notion of integrity in terms of
virtue.
Making Sense of Moral Constraints
Although the literature is full of complaints about the bad influence of the
market on the practice of medicine, it is difficult to find good arguments to
support those complaints. One reason for this may be a lack of sound descriptive
analysis in which statements about values are measured against statements about
facts. For that reason, avoiding mere exhortation is important.
Many of the problems we face in the delivery of health care today — in particular,
the problem of measuring the influence of the market against the canons of professional
integrity — stem from our inability, or unwillingness, to look squarely at
the situation created by the increasing institutionalization of medicine.
A kind of social myopia keeps health care professionals, in particular, from
seeing the connections between the practice of medicine and more general trends
in society. Health care professionals are, I believe, turning a blind eye to
the fact that the corrosive influence of commercial values on their profession
is an inevitable result of the dominance of those values in society as a whole.
Health care professionals reject market values in health care, but they tend
to be uncritical of the market's growing dominance in the larger culture.
The Institutionalization of Medicine
Sociologists of medicine, such as Steven Toulwin and David Rothman, point out
that since the end of World War II, the focus of health care in the United States
has shifted from the individual doctor's office to hospitals and clinics.4
What was once a personal relationship between health care professional
and patient is today an impersonal milieu of highly capitalized and bureaucratic
structures.
The social and ethical problems involved in this change will not be easy to
solve. Indeed, we are still far from having either acknowledged or analyzed
them.
In itself, the shift can be considered morally neutral. It means only that
health care is following the path traveled by other institutions in modern society.
Analogous shifts have occurred in virtually all other social organizations:
the church, the military, education, news media, and others. These changes have
historically brought problems of adjustment (even crises) resembling those that
have appeared in health care in recent years. Today's news media, for instance,
often seem more geared toward sales and ratings than toward the dispensing of
information.
This trend and its consequences were foreseen at the beginning of the 20th
century by a number of thinkers, including Emile Durkheim in France and Max
Weber in Germany. They came to the conclusion that a leading feature in the
growth of modern societies was the increasing differentiation of social functions.
All advanced industrial nations seemed to have a tendency toward bureaucracy
and institutionalization in which all forms of personal exchange lose the immediacy
of their origins and become increasingly complex.
In this more complex society, no institution can be seen in isolation. A large
hospital is, of course, a complex institution. Not just complex in itself, a
hospital also functions as part of a much larger structure — the U.S. health
care system. Both the h_spital and the system are driven by the same logic of
depersonalization and neutralization. The best example of this phenomenon is
what one might call the "super-system" — the market itself.
To describe the shortcomings of a modern society defined by greater differentiation
of social roles and increased bureaucratization in the operation of institutions,
Weber used the famous image of the "iron cage."5 In such
a deterministic system, professional callings become job descriptions; ethical
obligations give way to functional imperatives; individual responsibility is
replaced by institutional excuses.
This situation is particularly problematic when the claims of professional
integrity and institutional survival conflict. Victory inevitably goes to the
stronger. Institutions are more powerful than individuals, and market considerations,
in this culture, carry more weight than professional standards. The inevitable
result of such conflicts is the progressive devaluation of the moral claims
of professionalism in the interest of ensuring economic fortunes and the stability
of institutions.
No one denies that the tendency to centralize the delivery of health care in
large institutions presents great opportunities for medical research and practice.
In fact, we all benefit from them. However, those technical advantages are purchased
at the price of social and ethical disadvantages. To quote Toulwin again:
To the extent that, in the operation of a modern hospital, budgetary claims
tend to outweigh those of a moral calling, the institution acts like Weber's
"iron cage." Medical professionals collectively cease to be a profession.
The work of the individual health care professional, circumscribed by institutional
imperatives, is removed from the sphere of moral commitment and put instead
into the realm of social necessity. As a result, the work of such professionals
is inevitably de-moral-ized.6
Consequences Exemplified
I do not intend to promote a particular sociological theory here. The fact
that we may or may not agree with Weber's analysis is beside the point.
What I do want to provide is a heuristic device that might help readers
develop their own conclusions. However, Weber's thesis does help explain
some of the problems that have become daily experience for hospital administrators,
health care professionals, and patients.
Weber's picture of modern society — moving inexorably toward greater
differentiation of roles and greater bureaucracy — helps to clarify the dilemma
that contemporary health care administrators face. Their predicament is normally
described as "economic": They must develop strategies to defend their
organizations' budgetary soundness, on one hand, and its public reputation,
on the other. Following one such strategy, an administrator might encourage
his facility to establish (and enforce) high productivity standards, promote
vigorous utilization review — and avoid patients who lack insurance coverage.
Although unfortunate, and perhaps ethically wrong, these actions are entirely
consistent with the administrator's ability to act, given current reimbursement
levels and competition. One could even say that this is precisely what the administrator's
job requires him or her to do.
Such administrative practices have a notoriously large impact in health care
institutions. Physicians, for example, tend to see them as limiting their professional
discretion. What is worse, caregivers may begin relating to their patients in
a cynical rather than generous manner. When faced with the decision of whether
to play by the rules or fight them, many caregivers may choose to protect their
privileges rather than serve patient needs.
What about the patients of such an institution? One cannot blame them for the
growing suspiciousness they bring to their (increasingly brief) encounters with
health care professionals. The medical profession still likes to project a romantic
image of the doctor-patient relationship on such encounters. But, given the
obvious constraints, patients are rapidly coming to see that the image is unrealistic.
The Impact on the Notion of Integrity
When one takes seriously the current social trends in health care institutions
and refrains from facile moralizing about them, one is forced to admit that
the question of professional integrity needs to be radically rethought. The
problem with the complementary model of integrity and compliance — that it
does not address the larger context in which health care organizations function — is
now obvious. As long as we refuse to address that larger context — the hyper-market
culture in which commercial values dominate — we should not be surprised
if health care professionals capitulate to a complementary model of integrity
in which their behavior is governed by economic interests, their own interests
and those of the organizations they serve. The system's "iron cage,"
not their own lack of moral strength, will have already imposed this particular
model of integrity on them.
Of course, one could simply tell health care professionals to ignore the "iron
cage" and follow their consciences. But this individualistic approach misses
the point for two reasons.
Individualism and Commercial Culture The individualistic approach ignores
the larger cultural framework in which the individual professional operates.
When confronted with the shortcomings of an increasingly bureaucratic and impersonal
milieu, a professional (whether physician, nurse, social worker, or chaplain)
cannot help but feel powerless and frustrated. His or her institution has already
decided, through its resource allocation and other strategic decisions, the
degree of moral sensitivity with which professionals will be allowed to do their
jobs.
Nor can we blame the health care institution itself. After all, it is only
a part of the larger commercial culture — which has in turn already decided
the degree of moral sensitivity with which the institution will be allowed to
do its job. We should not be surprised if health care values mimic those
that drive societal relations in general.
What Edmund D. Pellegrino, MD, calls the "internal morality of medicine"
and others refer to as the "non-negotiables" of moral health care — justice,
patient-first orientation, and a notion of health that encompasses more than
physiological functioning — cannot exist in a vacuum as the isolated moral
insights of enlightened health care professionals.7
No "internal" morality of medicine can exist entirely separate from
the "external" morality that drives the whole of society. We cannot
seriously expect it to be found in a generation of young people brought up to
see competition and ambition as essential ingredients of success. The current
generation of health care professionals is being taught, at least implicitly,
that human relations are not values in themselves, but rather a means toward
egotistic return and profit. Even the best possible school, having such students
for no more than the few years of their professional education, would fail to
instill in them a substantially moral notion of integrity.
Individualism's Weak Impact The second problem with a purely individualistic
strategy is the fact that it would represent, at best, an act of goodwill and
would fail to have a real impact on society. Commendable as it might be, such
a strategy could be neither sufficiently effective nor prophetic.
Today's health care professionals should be playing an openly prophetic,
politically militant role in society. In fact, however, many professionals criticize
health care's increasingly for-profit mentality while, at the same time,
feeling perfectly comfortable with the for-profit thinking that shapes their
overall social outlook. No wonder such professionals are rarely found on the
front lines, reminding the rest of us that health care, a social good of a special
nature, is not a commodity like all the others.
Because larger cultural values inevitably influence health care values, health
care professionals must learn to act collectively, rather than individually.
As members of a profession (as well as individual professionals), they must
finally declare that, unless a profound social change occurs, they cannot practice
medicine any more. It is impossible to predict how such a prophetic, civic movement
might take shape.* I am convinced, however, that it must occur soon.
* Physician groups seeking health care reforms exist at
present. However, the movement I describe here will require a more thoroughgoing
and unified critique of the entire system.
Reconstructing Integrity
To address the real challenge, we must return to the Weberian metaphor of the
"iron cage."8 The image symbolizes the hypothesis that
many of the problems seen in contemporary health care are the result of society's
failure to look at the consequences of health care's increasing institutionalization.
The image may, moreover, have deep existential meaning for those health care
professionals who feel powerless, frustrated, perhaps even guilty because of
the things they are forced to witness, and do, in the name of the system. Many
such professionals feel incredibly frustrated.
How are we to reconcile the paradox of individual professionals who want to
behave with integrity while suffering the deterministic constraints of a system
about which they feel so powerless? Health care professionals will have to answer
that question for themselves. I can do no more here than make some suggestions.
I propose that we think of integrity as a virtue — as, in fact, the most
fundamental virtue. We obviously need to rethink the meaning of professional
integrity. We need to do so because, first, integrity does not necessarily depend
on compliance with the values of the organization or the system within which
one works; and, second, because the complexity of those organizations and that
system have made health care's fundamental values increasingly obscure.
This, at least, is clear from the Weberian thesis: The increasing differentiation
of roles has made it more difficult for professionals to define integrity. In
a simpler society, with simpler medical institutions, arriving at a definition
was probably easier. Those times, however, are gone for good.
In today's complex situation, thinking of integrity as a function of discernment,
entailing both intelligence and courage, may be helpful. For this reason, integrity
as a virtue is applicable to society, to organizations, and to individuals.
Integrity ought to define society's character. A society that can bear
the thought of having in its midst 39.3 million people who are uninsured — and
therefore have inadequate health care — cannot describe itself as moral.
Indeed, because "integrity" means "wholeness," the fact
that so many people lack adequate care indicates that the society itself lacks
integrity. The very existence of the uninsured is evidence that America still
has some distance to go if it is to reach true integration. The right
to health care is, to my mind, no less important than the right to education
or the right to political participation, struggles that this nation experienced
earlier in its history. Only within the historical framework of a society engaged
in political discourse about the integrity of its institutions can we make sense
of the notion of integrity as it applies to particular organizations and individual
professionals.
Of course, a new societal definition of integrity will require a redefinition
of the traits that make up an individual's integrity as well. Integrity,
as I see it, is the ability to reinvent oneself in the light of changing realities.
Integrity is not refusing to face change on the supposition that we already
know who we are; that kind of thinking can lead one only to resignation. Rather,
integrity is the courage that allows one to face complexity and to make sense
of it in light of who one wants to be. To have integrity is to know from
whence we come and to accept the risk of not yet knowing where we are going.
Literature offers us two different champions of integrity, Ulysses and Abraham.
The former understands integrity as nostalgia for a place in the past, to which
he aspires to return. The latter sees integrity as willingness to accept the
risk of a new definition and of a new land and destination. Today's health
care professional should, I think, resemble Abraham more than Ulysses. I cannot
describe in detail what the integrity of a professional might look like, but
I can recognize the faith.
NOTES
- Robert Kuttner, Everything for Sale: The Virtues and Limits of Markets,
Alfred A. Knopf, New York City, 1997, p. 57.
- See, for example, Theodor W. Adorno, Minima Moralia: Reflections from
Damaged Life, New Left Books, London, 1974, and several of John Paul II's
encyclicals, including Laborem Exercens, Centesimus Annus, and Sollicitudo
Rei SocialisL For a general commentary, see Charles E. Curran and Richard
A. McCormick, Readings in Moral Theology No. 5: Official Catholic Social
Teaching, Paulist Press, New York City, 1986.
- Kuttner, p. 62.
- See Stephen Toulwin, "Medical Institutions and Their Moral Constraints,"
in Ruth Ellen Bulger and Stanley Joel Reiser, eds., Integrity in Health
Care Institutions: Humane Environments for Teaching, Inquiry, and Healing,
University of Iowa Press, Iowa City, IA, and David Rothman, "Medical
Professionalism: Focusing on the Real Issues," New England Journal
of Medicine, April 27, 2000.
- Max Weber, The Protestant Ethic and the Spirit of Capitalism, Scribner's,
New York City, 1958, p. 181.
- Stephen Toulwin.
- See Edmund D. Pellegrino, "The Internal Morality of Clinical Medicine:
A Paradigm for the Ethics of the Helping and Healing Professions," in
Corrado Viafora, ed., Clinical Bioethics: A Search for the Foundations,
Kluwer Academic Publishers, Dordrecht, The Netherlands, forthcoming in
2002.
- For a recent commentary on the "iron cage" metaphor, see Charles
Taylor, The Ethics of Authenticity, Harvard University Press, Cambridge,
MA, 1992, pp. 93-109.
Copyright © 2001 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.