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Integrating Health Care Ethics

For an expanded version of this article

Effective managers know that success comes from assigning tasks according to individual and group abilities, and then combining those efforts to achieve a shared purpose. The same dynamic is necessary for success in applied ethics, but seems to have gone largely unrecognized. Ethicists analyzed the broad discipline of ethics to meet immediate needs. What remains to be done is to synthesize what ethicists and managers have learned from study and experience into an integrating model.

The complexity of organizational life demands a direct tie between ethics and policy and rejection of simple formulas or sets of universal values. However, applied ethics has responded by developing increasingly sophisticated, but separate, and narrow approaches: business ethics, government ethics, bioethics, codes of professional ethics, and environmental ethics to name just a few. Managers now need a model harmonizing these approaches: a tool to raise and treat the ethics issues they face daily.

With the integration of ethical approaches, the manager approaches ethical complexity equipped to achieve shared goals. Without integration, a toolbox of such narrow approaches results only in bounded ethical framing, ineffective ethical choice, impotent ethical leadership, and unethical actions: in sum, ethical chaos.

Ethics in Health Care

Applied ethics specialties may have lost sight of what traditional ethics was trying to accomplish: a good life for good people over a lifetime in society with others. Ethical integration is essential for all organizations. This may be especially true for health care, where there is a prevailing frustration among health care providers. "Business and health care do not mix," it is said. But, where health care is provided and funded by business, and received by business employees (and their families) as a significant part of compensation, this proposition is untenable. The expression reflects an unintegrated approach to health care ethics.

Integrating Applied Ethics

The Ethics Integration Model below depicts the integration of applied ethics. It portrays comprehensive applied ethics as composed of four overlapping, specialized circles of ethical framing, choosing, and action brought together by ethical leadership where they overlap.

Each circle represents an independent approach to applied ethics: the ethics of Essential Social Responsibility, Social Purpose, Organizational Life, and the Ethics of Ecological Relationships or Environmental Ethics. Within each circle are applied ethics approaches raising and treating issues distinct to its own arena. In this model, a contribution from each circle is a necessary, but not sufficient, condition for an effective ethics system. Ethical leadership, at all levels, identifies those approaches that are appropriate to a particular organization or community and integrates them.Visual

Within the Ethics of Essential Social Responsibility are three broad categories: government, for-profit, and not-for-profit. Each has broadly different responsibilities within society, which are of the essence of its nature. Each has different key participants. Each has different constraints on action.

The essence of government is the appropriate application of its monopoly on the exercise of coercion and violence: the police, the military, and the courts. Its key participants are governors, the governed, and taxpayers. Bureaucracy and stability characterizes its institutions.

The essence of for-profits is meeting the most urgent needs of owners and consumers through free exchange: business and the professions. Key participants are owners, employees, vendors/suppliers, consumers, and those affected by their activities: other people, communities, and governments. Profits and adapting to changing customer needs characterizes its institutions.

The essence of not-for-profits is meeting the needs and values of a community without coercion or exchange: charity or philanthropy. Its key participants are charitable organizations or associations, beneficiaries, and donors, and the community as a whole. Recognizing needs of the community and soliciting community support characterize its institutions.

These are the essences, but there is much overlap, which makes ethical policy more difficult. In the area of health care, Federal subsidization of corporate employee benefits and Medicare and Medicaid are examples.

The Ethics of Social Purpose includes biomedical ethics, nursing ethics, banking ethics, legal ethics, accounting ethics, engineering ethics, marketing ethics, or the military ethics, to name but a few. Which bodies of ethics apply to a particular organization depends upon its vision—and the tasks required to achieve it. Under some circumstances, such as a hospital in a combat zone, many of these ethics approaches would apply, and need to be integrated.

The Ethics of Organizational Life or Systems Ethics is the domain of the ethics structures, compliance systems, practices, procedures, and protocols necessary for a body of people to achieve shared visions in accordance with its core values and organizational culture. The thrust of organizational ethics is to increase human energy, knowledge, and trust, and to drive out fear. Systems ethics applies to all organizational life, regardless of specific social purpose. It shapes the conditions of organizational life, the content of dialogue or conflict resolution, and the context for the ethical framing, choosing, and actions of the other circles. It is where ethical leadership may perhaps best be exercised, again at all levels.

The Ethics of Ecological Relationships is the domain of the relationships between our species and world of which we are an integral part. It is the most fundamental of all approaches to applied ethics. It addresses who we are, what the rest of the world is, and our relationship to the world as a whole. In its most fundamental and comprehensive form, it is contains each individual's worldview. Following the distinction made by the great Austrian Economist, Ludwig von Mises, between worldview and ideology, the other three circles represent ideologies, ways thought to be good or best to deal with the world as a whole. But this circle of ecological relationship, represents what is the best way to approach the world of which we are an integral part. The others may be thought to have largely instrumental value. Ones relationship in the world is by definition an intrinsic value.

Toward Integrated Health Care Ethics

Turning to patient care, there is clearly an ethical dynamic that goes far beyond biomedical ethics alone. But, "the whole has often been likened to a jigsaw being pieced together by strangers, each of whom is only guessing at the picture." The Ethics & Policy Integration Model is designed to help the manager bring these pieces together.

First, patient care depends in part upon the nature of the entity. Is this a governmental, for-profit, or not-for-profit hospital? Each area has different organizational providers, users, and payers. In concept, one area is politically driven, one is market-driven, one is community support-driven.

To what extent is the patient funding his or her own care? Since the cost of health care is largely financed by third parties (government, employer-paid insurers, or charity), this raises complex issues of individual and social responsibility, which any comprehensive ethics of health care must surface and treat.

Should the answers to these questions even be involved in determining the patient's level of care? At first glance, the answer heard at the Emory course, a resounding no, seems right. But consider its implications. A governmental scheme typically provides something to which a limited part of a society is entitled at the expense of the rest, that is, the taxpayers. If government is single payer in a system, everyone is entitled at the expense of everyone else who pays taxes. This is inherently political, bureaucratic.

It can be no other way. Government patients have no real choice in the matter if they stay within the system. A veteran wishing to exercise his or her veteran's benefits must go through a bureaucratic process. Welfare claimants deal with still more. Otherwise, the patient in a governmental scheme can demand all the care he or she desires—effectively having an unlimited right to tap the taxpayer. It is much the same for the not-for-profit hospital since only the method (but not the source) of fundraising is different. Only the for-profit hospital provides the patient with a direct choice of services; the patient can take his or her (insurance) money elsewhere.

Second, some speak of biomedical ethics, and the physician's role in applying it, as though it were equivalent to health care ethics. But while biomedical ethics raises important health care issues, it is hardly comprehensive. Biomedical ethics, in its purest form, is only part of the social purpose of a health care system. Nursing, dealing more with care than cure, raises still other issues. Medical research and teaching raise still others. Biomedical ethics does not drive the health care system any more than engineering ethics drives uEPICn planning or the highway system.

Why? Because the essence of biomedical ethics leaves untreated significant ethical issues of individual and social responsibility, which impact all of us, health care providers in particular. At the 1997 Emory Intensive Course in Health Care Ethics, for example, a panel examined a hypothetical involving whether to provide lifelong health care to a 14-year old auto accident victim from various normative approaches: utilitarian, narrative, economic, and feminist. Not once was the concept of responsibility employed.

Consider the implications of such a view. A physician is to make a decision regarding the care of the patient without regard to the patient's responsibility for his or her own condition or the resources available. He or she owes a patient unlimited advocacy for treatment without regard to past causes or future consequences; the physician "deals with the problem at hand." It makes little difference whether patients pursue a dangerous lifestyle (smoked, refused to wear a helmet, used IV drugs, etc.), choose to live life on the streets, previously refused to follow medical advice, or sacrificed to be sure he or she could afford quality health care. Further, it is not relevant that resources of time, energy, and money are limited across the health care system.

Certainly at the moment of care, the physician should have the primacy of the patient's welfare in mind. That is a proper role of biomedical ethics. But reality requires that health care ethics take a broader view. Health care ethical framing and choosing must incorporate all appropriate approaches to ethics. Rationing of care does exist. One need only look at waiting lists in government single-payer systems to see it in action.

Where rationing exists, the physician is precluded from advocating for the patient when there are no resources available within the system. Are physicians then acting unethically? Is the system unethical? Surely neither can be considered unethical, since even the most liberal of health care policy proposals contain some limits. But if physicians in such systems, as well as the systems themselves, are deemed to be ethical, what meaning is to be found in a biomedical ethics of unlimited advocacy for the health care system as a whole? How can a system work when its principal decision-makers are charged only with "dealing with the problem at hand" and not with the system itself?

Thirdly, systems ethics makes a difference. Ethical leadership is difficult. The bounds of responsibility for the care of a patient in a large hospital are often unclear, perhaps even, as Daniel F. Chambliss suggests, purposefully blurred. Attending physicians make decisions bounded by the decisions and actions of interested others: administrator guidelines; day-to-day decisions by residents, nurses, and aides; and daily routines. Interdisciplinary fear characterizes much of hospital life: administrators vs. physicians, physicians vs. nurses, payers vs. providers, patients vs. the system.

Biomedical ethics ignores the systemic, organizational issues that Chambliss calls "ethical problems" as opposed to "ethical dilemmas." It ignores the difference between these and "ethical conditions," which cannot be changed, they just are and need to be dealt with, not solved. As a result, health care providers are left vulnerable to feelings of hypocrisy and fear when situations they deal with on a daily basis demand a broader view for resolution than biomedical ethics permits.

Taking such a narrow view results in physician decisions being constantly second-guessed by responsible others, who have different, equally limited, ethical perspectives. It places physicians and nurses into situations where they feel hypocritical precisely because they do, in fact, make decisions based upon the limited time, energy, and money available.

Finally, the Ethics of Ecological Relationships must be considered. Health care takes place within a context of evolving life. We influence evolution in many ways, ours and other life's—and potential life's. These ecological relationships define us. One way they define us is whether we are in harmony with our world, or at war with it. Whether we contribute to the world as a place for evolution, learning, and growth, or exploit it only as a means to maintaining existence. Even more at issue are the limits on action that we recognize on our capacity to influence the course of nature-and the evolution that naturally occurs within it. The fact that we have the power to do something does not mean that it should be done.

For example, to increase the quality of human life, is it appropriate, as a matter of policy, to destroy another species? E.g., the small pox virus. Recognizing that some species evolve faster than we, and our technologies, evolve, is it ethical or even effective over the long run to kill members of a species to improve the quality of human life? E.g., antibiotic regimens. When is quarantine of the infected appropriate? When does human life begin? What are the long-term consequences of cloning life, especially human life? What is to be done with hazardous waste, especially bio-radiological and infectious waste? How far can the quality of other species' lives be affected to improve the quality of human life? When does bringing a human being into the world or keeping a human being alive become inappropriate, unreasonably unnatural, or inhuman?

Implications for the Future

We need serious, concerted efforts to integrate health care ethics at all levels. An Ethics Integration Model provides a foundation for the health care provider to take a formal structural approach toward integrating at least biomedical, nursing, and organizational ethics with its essential social responsibilities, and those of other key stakeholders in the health care system.

An exciting part of the Emory Intensive Health Care Course was a structural approach reported by Mary Ann Bowman Beil of Memorial Medical Center, Savannah, Georgia. Her hospital has established and integrated a corporate ethics function and a biomedical ethics committee. Representatives from each committee meet monthly, integrate their perspectives, and present their views to the CEO, COO, and Chief Medical Officer. It is a great start toward dealing with ethical complexity, but essential social responsibility and accounting, marketing, engineering, and environmental ethics need formal voices as well.


On the theoretical level, we must put biomedical ethics into perspective and develop a truly comprehensive approach to health care ethics. On the practical level, we need structures integrating divers ethical perspectives. Taking both steps together, we will achieve the quality of care for patients, the quality of life for care givers, and the quality of dialogue on health care policy we need to avoid ethical chaos. In short, "Take two steps, and call me in the morning."

An earlier version of this article first appeared in the newsletter: Ethical Management.

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