Ministry Leadership — Organizational Ethics is "Systems Thinking"

May-June 2004

BY: ED GIGANTI

Mr. Giganti is senior director, ministry leadership development, Catholic Health Association, St. Louis

Among the characteristics of effective leaders in the health ministry described in the Mission-Centered Leadership Competency Model* is the profound courage to act on one's values and take risks consistent with those values. This competency of integrity, which pairs with the competency of spiritual grounding in the model's Vocation Cluster, includes the struggles and challenges that inner spiritual life undergoes as it seeks to express itself in action. Integrity becomes the personal basis for integrating the values and mission of Catholic health care with the business realities of the marketplace.

* For more on the Mission-Centered Leadership Competency Model, see "Assessing and Developing Leadership"

Leaders demonstrating this competency act from their values even when it is difficult, risky, or costly to do so, and these leaders, when performing at the highest level of this competency, create environments that nurture integrity in the others who minister with them.

The leader, it would seem, must be the primary agent of organizational integrity, right? Not exactly, Ann Neale, PhD, told the capacity audience in her presentation, "Organizational Ethics: Corporate and Mission Issues" during the March program, "Ethics in Health Care: The Catholic Perspective". "The character and integrity of the organization is not simply the aggregate of the moral agency of the individuals it employs," said Neale, who is senior research scholar at Georgetown University's Center for Clinical Bioethics, Washington, DC. Of course, ethical behavior ultimately is enacted by individuals, but understanding the complexity of organizational ethics requires a more comprehensive assessment.

Moral Individuals Won't Suffice
"Health care executives and workers should surely be morally upright individuals," Neale said. "Their being such, however, is no guarantee of their organization's moral integrity. Rather, an organization's moral integrity is evidenced in its policies, practices, and relationships, that is, in a moral posture that is not only distinct from the moral agency of management, medical staff, and employees, but that, in effect, transcends those individuals' moral agency."

Culture, Neale said, is a shorthand label for the character and moral agency embodied in the organization's infrastructure. It is made up of the assumptions, beliefs, and values that drive the organization. Organizational culture is built up, over time, from the decisions of individuals and the organization's interactions with the surrounding cultural ethos in which it lives.

A morally deficient organizational culture can prevail despite the intentions of morally upright managers, Neale said, just as a morally robust organizational culture can survive the moral weaknesses of individuals, even key leaders. "The organization's culture is not something that individuals can easily or quickly change, even individuals with excellent leadership skills," she said. (Conventional wisdom says it takes a leader at least six years to affect an organization's culture.) "That is because the moral character of an organization is an accumulation, from multiple sources, of attitudes, behaviors, and influences. Over time, the organization's management, clinicians and other staff, its trustees, and societal forces, especially the market, have shaped the way it understands and lives out its mission."

Neale's concern is that an emphasis on the individual as moral agent can give the impression that the personal moral integrity of the leader is tantamount to organizational integrity. This perspective fails to recognize the distinction between the ethical dimension of an institution's policies and practices and the moral uprightness of individual leaders. "Americans regard individual persons as the primary element of moral concern," Neale said. "This thinking can reinforce an ethical individualism which sees persons as radically independent, utterly self-reliant." What may be missed, she added, is the influence, and possibly even control, that organizations and the larger culture have on an individual's moral freedom.

"Systems Thinking" Is Needed"
To invoke the inspirational rhetoric of mission and values in a framework that is focused on individual moral agency does not do justice to the complex moral terrain in which individuals in the ministry operate," she said. What is needed, she told the audience, is a "systems thinking" approach to ethical issues. "Health care ethics is a type of systems thinking. It offers a framework that takes into account the connections among its various systems and understands their effects on one another."

As an example, she applied this systems thinking to the issue of providing good end-of-life care. Care at life's end that witnesses to God's love and compassion would be characterized by decisions reflecting the patient's values; an emphasis on pain and symptom relief; attention to alleviating the patient's and family's suffering; spiritual counseling; treatment decisions that demonstrate good stewardship of resources; and a recognition that care, not cure, is the goal. A systems thinking assessment of this issue, however, identifies realities of inadequate education in end-of-life care and a medical model—and its reward and incentive systems—that values cure over care. In such an environment, Neale said, it is unrealistic to place the sole burden for improved end-of-life care on individual moral agents. "Exhortations to individuals about good end-of-life care need to be accompanied by strategies to change the culture of medicine that perpetuates poor practice, to educate the public, to influence public policy.

"We would make more ‘moral' progress if we recognized the limits of individual moral agency and more carefully distinguished which dimensions of the issue required a moral response from the organization and/or society," she continued. A systems thinking approach to health care ethics recognizes the individual, organizational, and societal realms of ethics and the mutual relationships among them, she said. Such an approach involves a more nuanced appreciation of moral responsibility and more effectively addresses health care dilemmas in all their complexity.

Neale described this systems thinking approach as reflecting the "three realms of ethics" named by John W. Glaser, STD, senior vice president, theology and ethics, St. Joseph Health System, Orange, CA, and author of Three Realms of Ethics (Sheed and Ward, 1994). In visualizing the three realms as nested—the individual realm in the organizational, the organizational realm in the societal—the framework highlights the significant influence the societal realm has over the other two. "For instance, because the market reigns supreme in our culture, the prevailing cultural value is profit," Neale said. "Most of us in health care have experienced the influence of the market on both our own moral agency and that of our organizations. Who, in advocating for the medically underserved, has not tempered her idealism because of market realities?"

But ultimately, the pressure of the societal realm does not absolve individuals or organizations of moral responsibility, Neale said. "Since the mission—to be signs and agents of God's love and compassion—remains, and since the individual or organizational freedom to be and do such is constrained, both individuals and organizations are obliged to advocate for structural changes in the societal realm," she said. "Individuals and organizations have a moral responsibility to effect social change because the mission depends on it."

No "Ethics-Free Zones"
In the life of the Catholic health care organization, there are no "ethics-free zones" because virtually every organizational function has an impact on human dignity. "The organization is a vehicle, which through its organizational functions is accomplishing the mission," Neale told the audience. "The mission is not something other than what the organization does. In performing everyday functions in accord with its vision and values, the organization is sign and agent of God's love and compassion. Organizational integrity, then, is the way the ministry continues Jesus' mission of radical healing."


About the Conference
The conference at which Ann Neale spoke, "Ethics in Health Care: The Catholic Perspective," was cosponsored by CHA and the Neiswanger Institute for Bioethics and Health Policy at the Stritch School of Medicine of Loyola University Chicago. It was held March 3-5, 2004, in Chicago. More than 150 people attended the two-and-one-half-day conference and heard presentations by Fr. Kevin O'Rourke, OP, JCD, the conference director, and a faculty of noted ethicists from Catholic health care, including CHA's senior director of ethics, Ron Hamel, PhD. CHA and the Neiswanger Institute will cosponsor a similar conference March 2-4, 2005, at the medical school campus in Maywood, IL.

Neale is the author of the online document, Organizational Integrity in Catholic Healthcare Ministry: The Role of the Leader.

 

Copyright © 2004 by the Catholic Health Association of the United States
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