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Organization Ethics
in Health Care
EDWARD M. SPENCER
ANN E. MILLS
MARY V. RORTY
PATRICIA H. WERHANE
New York Oxford
OXFORD UNIVERSITY PRESS
2000
Oxford University Press
Oxford New York
Athens Auckland Bangkok Bogotd Buenos Aires Calcutta
Cape Town Chennai Dar es Salaam Delhi Florence Hong Kong Istanbul
Karachi Kuala Lumpur Madrid Melbourne Mexico City Mumbai
Nairobi Paris Sao Paulo Singapore Taipei Tokyo Toronto Warsaw
and associated companies in
Berlin Ibadan
Copyright © 2000 by Oxford University Press, Inc.
Published by Oxford University Press, Inc.,
198 Madison Avenue, New York, New York, 10016
Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Spencer, Edward M.
Organization ethics in health care /
Edward M. Spencer... [et al.].
p. cm. Includes bibliographical references and index.
ISBN 0-19-512980-6
1. Managed care plans (Medical care)—Moral and ethical aspects.
2. Medical ethics.
3. Corporate culture—Moral and ethical aspects.
1. Title."*] A
[DNLM: 1. Ethics, Medical.
2. Health Facilities—organization & administration.
3. Organizational Culture.
W 50 S745o 2000] RA413.S64 2000 174'.2—dc21
DNLM/DLC for Library of Congress 99-31080
9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
Preface
This book represents a new approach to healthcare ethics. Unlike previous alter-
native approaches to ethics in health care, we are advocating a focus on the ethics
of the entire organization, a focus that encompasses and integrates the resources
and activities of clinical ethics, business ethics, the ethics of healthcare manage-
ment, and professional ethics within the organization. This inclusive perspective
we call "organization ethics."
Although we will discuss managed care organizations (MCOs) and health
maintenance organizations (HMOs), the primary subject of this book will be
medium-sized and large organizations that provide health services. We start with
provider organizations, because many of these healthcare organizations (HCOs)
have well-established institutional clinical ethics committees that deal with ethi-
cal issues in patient care. Thus thinking about ethical issues on an institutional
level is not alien to HCOs even if these ethics committees have not concentrated
specifically on business, professional, or organizational issues. If provider orga-
nizations can create organization ethics programs that integrate clinical, medical,
professional, and economic perspectives while delivering high-quality health ser-
vices, such organizations will serve as models for MCOs, HMOs, preferred pro-
vider organizations (PPOs), and other organizations in the business of purveying,
funding, and, in some instances, delivering healthcare services.
The book is both a theoretical analysis of the ethics of healthcare organizations
and a guide to how, in practice, a viable, robust, inclusive ethics program can be
developed within a healthcare organization. Thus the audience for the book is not
merely those who teach healthcare ethics and healthcare administration, and their
students. The book is also written for practicing healthcare administrators and
professionals who struggle daily with ethical issues in managing and providing
health care to a patient population in community settings where demands for high-
quality health care is acute. Teachers using the book in the classroom will find
the philosophical dimensions of organization ethics important for students. Prac-
ticing healthcare managers and professionals may well want to focus their atten-
tion on chapters 9-12 of the book, where the practical implications of our thesis
are worked out in some detail.
Chapters 1 through 5 of the book introduce our thesis and discuss questions of
organizational ethics, and the limitations of clinical ethics, business ethics, and
professional ethics to address many of the recent changes in the HCO and the
relationships among its key stakeholders. Chapters 6 and 7 describe the historical
vi PREFACE
development of the HCO and explore the external environment in which the HCO
is operating today. Chapters 8 through 11, discusses the internal ethical climate
of the HCO. This part of the book offers detailed recommendations for the imple-
mentation of a successful organization ethics program. A more detailed descrip-
tion of each chapter follows.
Chapter 1 introduces the reader to the concept of organization ethics and looks
at some of the initiatives that important regulatory and representative groups have
made in that direction. We begin to differentiate our approach to organization ethics
in this chapter.
Because this is a book about organization ethics, in Chapter 2 we outline fur-
ther what we mean by ethics, and introduce the reader to some prominent ethi-
cal theories. We then shift attention from individuals to organizations. We deal
with the question of organizational roles and role morality, and suggest how one
can hold an organization, as well as the individuals who constitute it, morally
responsible.
Chapter 3 focuses on patient care or clinical ethics. We trace its roots in bio-
ethics and medical ethics and explain how its use of casuistry is an effective
approach in dealing with ethics issues in HCOs. While institutional ethics com-
mittees are by and large clinically focused, we argue that that framework can be
reconceptualized in thinking about organization ethics committees. Chapter 4
addresses business ethics. There we discuss the limitations of a model that sug-
gests that a manager's responsibility is primarily to shareholders, and we refor-
mulate that responsibility in terms of the mission of a HCO. We then reframe
normative stakeholder theory to take into account the unique priorities of HCOs,
and their complex accountability relationships.
Chapter 5 concentrates on professional ethics. We show that while the profes-
sions, like HCOs, prioritize patient care as their primary concern, most profes-
sional associations have yet to think through implications of healthcare organiza-
tions for their professionals, most of whom are now employees as well. The
challenge is to capture the professional priority of the value-creating activity of
providing patient care in an organizational setting.
Chapters 6 and 7 discuss the historical development of healthcare organizations
in the United States, the external social, religious, technological, and political
climates in which they grew and were changed, and the present-day state of af-
fairs in health care in the United States. We identify in these chapters four distinct
shifts in the HCO's orientation. We argue that all but the last shift has occurred
within the context of values that have been articulated and endorsed by society.
These chapters are important to students of health care to give them a context within
which to comprehend the healthcare situation in the United States as we move
into the new millenium. Many readers will be familiar with the history of the HCO
and may be tempted to gloss over these chapters. However, we believe our concep-
tualization of it supports our earlier theoretical contentions.
Preface vii
Given the theoretical background developed in the early chapters and the his-
torical, political, social and technological context out of which health care is de-
livered today (Chapters 6 and 7), the reader is then prepared to begin thinking
about how ethics, ethics programs, and ethics committees can make a difference
in healthcare organizations, and why such initiatives are crucial for the future
survival and flourishing of health care. Chapter 8 begins this task by analyzing
how an HCO can develop a positive internal ethical climate given today's social,
political, and market forces. Chapter 9 outlines the nuts-and-bolts task of institut-
ing an organization ethics program within an HCO. Given those recommenda-
tions, in Chapter 10 we focus on issues in quality, compliance, and risk manage-
ment as ancillary problems for an organization ethics program. Finally, in Chapter
11, we discuss questions concerning evaluation of the program and its activities.
Developing an organization ethics program that is truly mission driven, that inte-
grates all aspects of the HCO, and that creates a positive ethical climate that drives
values-based decision making is truly a daunting endeavor. But, we will conclude,
it is worth the effort. Trust of HCOs and in the managers and the professionals who
work there will be reinvigorated and the issues of financing and delivery of health
care can be dealt with adequately within the context of a well-articulated and broadly
agreed upon mission and positive ethical climate. Organization ethics is an impor-
tant challenge to HCOs and all who work in the healthcare arena. How this industry
and the healthcare professions respond to this challenge will determine the course
of health care in the United States for the foreseeable future.
This project has been supported by the Olsson Center for Applied Ethics in the
Darden Graduate School of Business Administration and the Center for Biomedi-
cal Ethics in the School of Medicine, both at the University of Virginia. In par-
ticular we thank Jonathan D. Moreno and R. Edward Freeman for their encour-
agement. We also are gratefully appreciative of the Ethics Institute at the American
Medical Association for providing a think tank to generate some of these ideas.
We wish to express our deep appreciation and gratitude to Carlton Haywood Jr.,
our student and intern, who has assisted us in the preparation of this manuscript.
Our appreciation and thanks as well to Emily G. Powell and Karen F. Musselman.
In addition, the book has benefited from discussions we have had with hundreds
of students, academics in applied ethics, and practicing healthcare professionals
and managers who are concerned about the present and the future state of health-
care delivery in this country. The editors at Oxford University Press, in particular
Jeffrey House and Charles Annis, have encouraged and supported the genesis and
delivery of this book. Its shortcomings are our own.
Charlottesville, Virginia E. M. S.
April 1999 A. E. M.
M. V. R.
P.H.W
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Contents
1. The Background for Organization Ethics, 3
2. A Philosophical Basis for Organization Ethics, 15
3. Clinical Ethics and Organization Ethics, 31
4. Business Ethics and Organization Ethics, 49
5. Professional Ethics in Healthcare Organizations, 69
6. The Relationship of Social Climate to the Historical Development
of the Healthcare Organization and its Ethical Climate, 92
7. The Ethical Climate in Today's Healthcare Organization, 118
8. Developing a Positive Ethical Climate in the Healthcare Organization, 136
9. Instituting an Organization Ethics Program, 151
10. Compliance, Risk-Management, and Quality-Improvement Programs, 171
11. Organization Ethics Activities and Their Evaluation, 186
12. Conclusion, 200
Appendix 1. Virginia Bioethics Network Recommendations for Guidelines
on Procedures and Processes to Address Organization Ethics in
Health Care Organizations, 211
Appendix 2. Towards a Pragmatic Method for Assessing Moral Problems, 216
Appendix 3. A Decision Process: A Framework for Moral Reasoning, 218
Appendix 4. Codes of Ethics, 219
x CTttONTENTS
Appendix 5. The Rise, Fall, and Reemergence of the Nursing Home:
Important Lessons to be Learned, 225
References, 229
Index, 237
Organization Ethics in Health Care
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1
The Background for Organization Ethics
Scrutiny of the ethical operations of larger non-healthcare-related corporations is
not new. Beginning shortly after the Watergate scandal, both governmental watch-
dog agencies and private groups have been showing an increasing interest in how
corporations address ethical issues. Recent specific cases of ethically problem-
atic activities in a number of corporations have received particular attention and
criticism, and, within the corporations themselves, have led to the development
of compliance and ethics programs as attempts to meet the criticism. Originally,
the mission of these programs was not always focused on the ethical climate of
the organization or on the details of the decision-making process within the orga-
nization. Rather, illegal activities such as fraud, improper handling of funds, un-
scrupulous practices, or overtly immoral behavior (usually sexual harassment is-
sues) constituted the majority of cases of concern. Such programs that developed
along these lines were more clearly compliance programs than ethics programs,
although they were often labeled "ethics." The aim of a compliance program is to
make sure a company complies with regulations, laws, and those societal norms
for which there is general consensus. The aim of an ethics program is to develop
and evaluate the organizational mission, to create a positive ethical climate within
the organization that perpetuates the mission, to develop decision models for in-
suring this perpetuation as reflected in organizational activities, and to serve as a
cheerleader, evaluator, and critic of organizational, professional, and managerial
3
4 ORGANIZATION ETHICS IN HEALTH CARE
behavior. Compliance is part of that, since disobeying the law or circumventing
regulations is ordinarily not considered appropriate moral or legal behavior. How-
ever, an ethics program is broader and its mandates less clear-cut than compliance.
Recently, corporate compliance and ethics programs have been encouraged by
the federal government with its advancement of the Federal Sentencing Guide-
lines for corporations. These guidelines specify appropriate sentences for indi-
viduals and institutions found guilty of specific criminal activity. Because sen-
tences under these guidelines can be mitigated when the guilty organization can
demonstrate that it has in place a "effective program within the organization which
seeks to deter and prevent criminal activity" (Federal Sentencing Guidelines,
1995a), most corporations have begun such activities under the rubrics of "cor-
porate compliance programs" and "ethics programs."
Until the recent increase in attention to HCOs by federal authorities, ethics pro-
grams in those institutions had been primarily focused on ethical issues related to
the care of individual patients. Since the late 1980s and early 1990s, the missions
of most HCOs' institutional ethics committees have been to protect the rights of
the individual patient. Before this, healthcare regulators and accrediting agencies
saw the institutional ethics committee, along with Medicare and Medicaid regu-
lations affecting patient care, as adequate protection for the patient, leaving HCOs
with little to fear from the Justice Department. Consideration of ethical issues
outside the patient care and research arenas was mainly restricted to employee
relations, for which there were often specific contracts, policies, and guidelines
required by law.
As HCOs, MCOs, HMOs, and other healthcare payers and providers have grown
and become increasingly complex, they have begun to receive more negative at-
tention from the Justice Department, with particular emphasis on nonadherence
to Medicare and Medicaid regulations, leading to questions of potential fraud or
other criminally liable activities. The advent and rapid market penetration of
managed care has increased this scrutiny. The Justice Department is now looking
at HCOs' compliance to government regulations as well as their obedience to laws,
thereby assuring the application of sentencing guidelines in the healthcare indus-
try just as they have been applied in other industries. It has now become clear that
HCOs need a mechanism to respond to externally imposed regulations and re-
quirements affecting institutional operations, requirements that have only recently
begun to be relevant in the healthcare arena. HCOs have also become more aware
of the ethical issues related to their business functions. This response mechanism
is being called "organization ethics" and is already an important primary respon-
sibility of the HCO; a responsibility that, if ignored, can harm the HCO, both as a
business and as a healthcare provider.
With Justice Department attention as a stimulus, larger HCOs and health-
care systems, like non-healthcare-related corporations, have instituted or are con-
sidering instituting a corporate compliance program or an organization ethics
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