Sr. Lappetito is senior associate for corporate and social ethics, Catholic Health Association, St. Louis.
This column marks the beginning of a regular feature in Health Progress. Its purpose is to alert managers to the ethical dimensions of issues they face and to provide them with new ways of thinking about these issues.
More than a year ago, members of the Catholic Health Association's Division of Theology, Mission, and Ethics began to notice that Catholic healthcare administrators were becoming increasingly concerned about questions related to managing and directing healthcare institutions. A growing number of members were contacting CHA with questions about values that are embodied in corporate structures, processes, and policies and that shape the formulation of new ones.
The questions being raised clearly were not limited to patient care and clinical ethics. These inquiries were drawing attention to the healthcare facility as an employer and as a community institution that has social responsibility for the resources entrusted to it. The fundamental question was this: How should a Catholic not-for-profit healthcare institution relate to all the persons who have a legitimate interest in how it functions? Who are the stakeholders, and what values should underlie the institution's relationships with them?
To respond to the growing ethical concerns surrounding a healthcare facility's corporate, social, and business dimensions, CHA formed a task force of experienced healthcare ethicists (see "Task Force on Healthcare Management Ethics" at the end of this article). The task force established three goals:
- To hold focus groups to identify the ethical issues faced by management in Catholic healthcare
- To describe more fully the focus of healthcare management ethics
- To design a process that would facilitate ethical decision making by administrators and managers
What Are the Ethical Issues?
The task force convened three focus groups to test the accuracy of the perception that interest in healthcare management ethics was indeed growing. The task force invited chief executive officers, chief operating officers, chief financial officers, planners, mission effectiveness and human resource personnel, and others to share at least one ethical issue that troubled them and why.
The ethical questions raised covered a broad spectrum. The following is a sampling:
- Planning: How do we balance the need for institutional growth and stability with the needs of the community being served? Do institutional needs have priority over community needs?
- Human resources: How can we reduce our work force when needed while minimizing the negative effects on the employees laid off, their families, and the employees who remain?
- Finances: What values drive the budgeting process? Are the needs of the poor and underinsured deliberately reflected in the budget? How large does the margin have to be, and for what purpose? How can we incorporate values into investment decisions?
- Legal issues: Do legal considerations drive the treatment of clinical cases? How do we resolve differences when legal advice conflicts with the organization's values?
- Patient confidentiality: Given the advent of new technologies, what kind of information should be gathered, and who should have access to it?
Why Healthcare Management Ethics?
Healthcare management ethics is a new endeavor in the field of ethics. The need for this branch of ethical inquiry grows out of the rapid development of our complex American healthcare system.
In addition, the lack of consensus among the American public on the nature, meaning, and value of health and healthcare reflects deeply rooted value conflicts. The differences in public opinion are often demonstrated in heated debates. The resulting social and economic dilemmas highlight the need for reflection. The lack of clarity often subjects healthcare managers to the whims of political and economic forces. The confusion and differences point to the need for a well-articulated body of knowledge in support of the concept that healthcare is a social good and not simply a commodity accessible only to those who have the ability to pay.
What Is Healthcare Management Ethics?
In making healthcare services available, managers make many routine operational decisions. Healthcare management ethics deals with the values that confront managers in the healthcare environment. Ethical reflection involves being aware of an issue and its many ramifications, including its impact on the institution and its stakeholders.
The underlying question is, What values are at stake for all parties involved? Thus healthcare management ethics begins with the recognition that decisions are value driven, and it seeks to ensure that the decisions which are made within a Catholic healthcare facility reflect the organization's values.
How Do We Apply Healthcare Management Ethics?
The task force developed a process to help executives and managers analyze and address the ethical dimension of the issues that confront them. The word "process" warrants emphasis, for ethical reasoning does not dictate specific, ready-made answers to ethical issues. Rather, ethical reflection involves a multifaceted reasoning process that progresses through several phases to achieve morally appropriate resolutions. Because the issues are so complex, the process will seldom unfold in a simple, linear sequence.
Understand the Issue The starting point for ethical decision making is a full understanding of the issue. This requires an awareness of the values involved. What are the implications of the organization's values and the Catholic Church's moral tradition? What values are of concern to the various stakeholders? In addition, appropriate data has to be gathered, recognizing the interplay between the values involved and the data that are sought.
Identify the Dilemma From an ethical perspective, the reason a decision has to be made is that all the values at stake cannot be fully realized. What values are in conflict?
Determine the Most Important Value Of the values in conflict, which are the most important?
Make a Decision Among the most realistic options available, which one (1) maximizes the most important values—recognizing that a perfect solution is rarely available—and (2) in some way does not overlook the other values at stake.
Implement the Decision Subsequent phases of the process entail implementation of the decision, testing of the results, and establishing accountability processes.
Testing the Process Over the next year, the task force plans to test this process for management ethics. Administrative teams at several sites throughout the country have presented case studies of particular ethical problems, and members of the task force will help them use the decision-making process to work through their dilemmas.
An Accelerating Need
Changes in healthcare technology and the healthcare delivery system are accelerating, creating the need for a process of values-based ethical reflection on new, often barely defined issues. Throughout the coming year, this column will explore a wide range of ethical questions related to such areas as finance; telecommunications; information systems; professional relationships; public policy; human resources; and marketing, planning, and development.
Please feel free to contact a member of the task force if you want more information about this column, the ethical decision-making process, or any other aspect of healthcare management ethics.
Task Force on Healthcare Management Ethics
Sr. Joanne Lappetito, RSM (Chairperson)
Senior Associate, Corporate and Social Ethics, Catholic Health Association, St. Louis
Gerry Magill, PhD
Professor of Moral Theology and Business Ethics, Saint Louis University
Ann Neale, PhD
Vice President, Advocacy and Corporate Ethics, Franciscan Health System, Aston, PA
Thomas F. Schindler, PhD
Director of Ethics, Mercy Health Services, Farmington Hills, MI
Leonard J. Weber, PhD
Director, the Ethics Institute, University of Detroit-Mercy
Copyright © 1993 by the Catholic Health Association of the United States
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