The picture opposite, a deserted street in Keet Seel, an
ancient Anasazi village in northern
Arizona, serves at once as both a lifeless and vivid reminder
that the complexity of life demands a direct tie between
ethics and policy for our communities to be sustainable
and capable of further evolution. In "simpler"
times, people holding shared purposes, values, and visions
of a desired future lived and died in communities like Keet
Seel. Such villages provided hope, identity, and purpose
for their members. In our relatively more complex times,
organizations of all sorts and sizes provide a substantial
measure of hope, identity, and purpose for its members as
The Anasazi, who built and populated Keet Seel among hundreds
of other villages, survived and thrived as a culture for
over a millennium. They lived in a harsh, dramatically beautiful
environment, only to leave the high desert plateau they
had called home within a few generations of building such
villages. Leaving relatively suddenly, and over a short
period in the thirteenth century, they ultimately lost their
separate identity as they merged with other tribes. They
left more questions than their ruined villages, pots, rock
art, and middens can answer.
If we are to achieve "sustainability," and avoid
the fate of the Anasazi, the first step must be to learn
to think and dialogue systemically in terms of levels of
consciousness, connectedness, and processes. In sum, to
link our ethics-especially developing notions of social
responsibility and organizational ethics-and our policy
at all levels of our society.
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
Integrating Applied Ethics
Ethics and policy integration is essential for all organizations,
but let us use health care-a basic human need-to flesh out
a framework integrating applied ethics and social responsibility.
The Ethics & Policy Integration Model, opposite, depicts
the integration of applied ethics and policy. It portrays
a comprehensive applied ethics and policy framework for
systems thinking and dialogue. This framework is composed
of four specialized circles of ethical consciousness, communicating,
choosing, acting, learning, and being all brought together
by ethical leadership where they overlap at the sigma point
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.
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
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 visionand
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
Toward Integrated Health Care Ethics
Turning to patient care, there is clearly an ethical dynamic
that goes far beyond biomedical ethics alone. However, "the
whole [of medicine] 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
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
Should the answers to these questions even be involved
in determining the patient's level of care? At first glance,
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 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
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."
In this view, it makes little difference that patients
pursue dangerous lifestyles (smoked, refused to wear a helmet,
used IV drugs, drove while talking on a cell phone, etc.),
choose to live life on the streets, and refuse to follow
medical advice. They are entitled to the same care as those
who sacrificed to maintain good bodily and mental health
and to be sure he or she could afford quality health care.
Further, under this view, it is not relevant that resources
of time, energy, and money are limited across the health
Certainly at the moment of care, the physician should have
the primacy of the patient's wefare 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
Rationing of care does exist. One need only look at waiting
lists in government single-payer systems to see it in action.
Moreover, where rationing does formally exist, the physician
is generally 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 the provider nor the system can be deemed
unethical, where 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 under these circumstances,
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, organizational 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
as a whole.
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 and policy 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, yes,
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 lives-and potential lives. 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 na-ture-and the
evolution that naturally occurs within it. The fact that
we have the authority to shape our lives, that is, 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,
Training, Education and Development
At the S point, the point where all four circles overlap,
lie the skills, knowledge, understanding and attitudes ("SKUA")
necessary for shared purposes to be achieved, informed choices
to be made, authority to be exercised, and learning and
growth to occur. Together, the SKUA are es-sential for the
necessary systemic thinking and dialogue to occur. The role
of ethical leadership, then, is to bring together the required
capacities and competencies through training, education,
It is helpful to organize the S point SKUA into eight elements
of ethics and policy integration:
- Consciousness: caring, awareness, commitment, and/or
- Comprehensive thinking: critical, creative, and systemic
thinking; choosing, judgment
- Communicating: dialogue involving feelings and ideas
Cooperating: inquiry and action
- Exercising authority: leadership, followership, participation
- Knowledge: surfacing, capturing, sharing knowledge,
including that which is tacit; knowing what you know,
and what you don't know
- Pride: self-esteem; stakeholder satisfaction and loyalty;
and community sense of being
- Time: time preference, time frame, time available
Visualizing such a matrix, there is for each of the eight
elements a package of training, education, and development
to build and shape the SKUA required to be competent. Moreover,
for ethics and policy to be integrated toward systemic thinking
and dialogue and cooperative inquiry, action, and learning,
these SKUA need to be developed at all levels of society:
individual, family, organizational, community, nation, and
Implications for the Future of Health Care
We need serious, concerted efforts to integrate applied
ethics and social responsibility at all levels, especially
health care ethics. The Ethics & Policy Integration
Model demonstrated here provides a foundation for the ethics
and policy leader, academic, health care provider, and others.
It allows them to take a formal structural approach toward
integrating biomedical, nursing, and organizational ethics
with its essential social responsibilities, and those of
other key stakeholders in the health care system, including
One structural approach in the health care arena is to
integrate organizational ethics, social purpose, environmental
ethics, and social responsibility functions and committees.
Committees of responsible people would be formed for each
discipline and meet as often as appropriate. Repre-sentatives
from each committee might meet monthly, integrate their
perspectives, and present their views to the Chief Executive
Officer, Chief Operations Officer, and Chief Medical Officer
in a hospital, for example. This deals with ethical complexity
by giving essential social responsibility and environmental
ethics formal voices as well as the more commonly heard
voices of social purpose and, to a lesser degree, organizational
Hopes for building sustainable communitiessocially,
culturally, and physicallymust be founded on learning
to think and dialogue systemically. The Ethics & Policy
Integration Model provides a framework for bringing together
the remarkable work that has been done in ethics and policy
toward that end. It is founded, in turn, on the four fundamental
concepts of shared purpose, informed choice, responsibility,
and learning and growth.
Again, using health care ethics as the example, on the
theoretical level, we must put biomedical ethics into perspective
and develop a truly comprehensive approach to health care
ethics. Such an approach would take into account broader
individual and social responsibilities. It would deal with
the environmental aspects of both care and cure. It would
address the toll the health care system places on its practitionersand
that its practitioners place on one another. On the practical
level, we need structures and systems integrating diverse
ethical and policy 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. Though it is not a simple or quick
process, "Take two steps, and call me in the morning."
 Moreover, the schism between ethics and social responsibility
may be especially true for health care, as there is a prevailing
frustration among health care providers. "Business
and health care do not mix," they complain. However,
where health care is provided and funded by businessand
received by business employees and their families as a significant
part of compensationthis complaint is untenable. It
reflects an unintegrated approach to health care ethics
 Linda K. Treviño and Katherine A. Nelson, Managing
Business Ethics: Straight Talk About How To Do It Right
(New York: John Wiley & Sons, 1995), 6, 72.
 Kenneth W. Johnson, "The Joy in Taking Responsibility.
" Remarks to the Cadets
of Valley Force Military Academy and College (April
 See also a four-part definition of corporate social
responsibility (economic, legal, ethical, and philanthropic)
in Archie B. Carroll & Ann K. Buchholtz, Business &
Society: Ethics and Stakeholder Management 4th ed. (Cincinnati,
OH: South-Western College Publishing, 1999), 33-38.
 "Systems Thinking/Systems Talking About 'Social
Responsibility'" Ethical Management (May 1996); "'Doing
Well By Doing Good'? Well, why Not?" Ethical Management
(July 1996). These articles concentrated on the social responsibilities
of business. These three levels of social responsibility
bear a deceptive degree of similarity to Lawrence Kohlberg's
levels of moral development. Lawrence Kohlberg, "The
Claim to Moral Adequacy of a Highest Stage if Moral Judgment,"
The Journal of Philosophy (Vol. LXX, 1973), 630-646.
An earlier version of this article first appeared in the
newsletter: Ethical Management.