6.1

HC-BS415_Week6_PP1.pptx

Chapter 10

Ethics in Health Leadership

“Healthcare executives should view ethics as a special charge and responsibility to the patient, client, or others served, the organization and its personnel, themselves and the profession, and, ultimately, but less directly, to society.”

American College of Healthcare Executives, 2009

Learning Objectives

Define distributive justice, ethics, morals and values. Describe how they are used by leaders in decision making.

Explain four ethical principles that guide decision making associated with patient care.

Apply at least two ethical frameworks/Distributive Justice Theories, with examples of moral practice of a leader, to an ethical issue in a health organization.

Learning Objectives

Analyze arguments and make a recommendation for health leaders to adopt Utilitarian and/or Deontological postures in their organization and differentiate potential decisions leaders would make between the two frameworks to support your analysis and recommendation.

Compile a list of available options a leader in a health organization has to develop an integrated system of ethics and moral practice and summarize the potential impact of each option regarding appropriate ethical adaptation across the organization.

Learning Objectives

Compare and contrast at least three ethical frameworks/Distributive Justice Theories for the topics of patient autonomy, beneficence, non-maleficence, and justice, and interpret the moral practice associated with those frameworks (at least three) for a Right to Life Issue and for the practice of Euthanasia.

Ethics in Health Leadership

Introduction

Ethics and the application of ethics, morality, are leadership responsibilities.

Too often, ethics, ethical practice and discussions of ethics are placed in a legal context of liability reduction and ‘legalism.’

Ethics in Health Leadership

Introduction

Health organizational culture development that includes an ethical framework, systems integrated in ethical expectations and moral practice of ethical actions and behaviors are leadership responsibilities not legal counsel responsibilities.

Health leaders model the behavior expected in the organization; this especially includes being a moral actor.

What are Ethics?

Ethics is defined as a moral philosophy between concepts of right and wrong behaviors linked to resource allocation.

It deals with values relating to human conduct with respect to the rightness and wrongness of actions and the ‘goodness’ and ‘badness’ of motives.

Ethics in the health field can further be defined as set of moral principles and rules of conduct for health professionals to follow

Ethics in Health Leadership

What are Ethics?

Ethics can, at times, be culturally defined also.

This links back to the Distributive Justice Theories, cultural values and beliefs and how a culture selects and applies a model of resource allocation based on societal norms and mores.

Ethics in Health Leadership

The Difference Between Ethics, Values and Morals

Values are enduring beliefs based on some early form of indoctrination and experience. Values are learned from parents, the community, school, peers, professional organizations and personal self development, to name only a few areas. Recall Rokeach’s model of Values-Beliefs – Attitudes.

Morals are applied practices derived from an ethical framework that is based on values and resource allocation beliefs. Different from values, morals comprise the principals on which decision making is based.

Ethics in Health Leadership

The Difference Between Ethics, Values and Morals

Morality is the level of compliance to an ethical framework.

Morals are the actions and outcomes of the human condition processed over time as evaluated against the ethical framework based on values and resource allocation principles.

Ethics in Health Leadership

In Aesop’s fable of The Grasshopper and the Ants

The ‘moral’ of this story is that it is always best to prepare for one’s future in the face of the uncertainty of the environment. However, because this ‘lived experience’ may take an individual’s entire lifetime to learn, the experience is shared through the lived experience of other’s through moral tales.

Ethics in Health Leadership

Setting an Ethical Standard in the Health Organization

Health leaders face ethical dilemmas in the daily work of delivering health services and products within the health organization.

Health leaders may often find themselves torn between owing allegiance to the financial stability of the organization and the charitable nature of the health profession.

Stakeholder expectations are expressed and integrated through board of director or board of trustee membership that represents the communities served and the advocacy of stakeholder expectations by senior leadership of the health entity and within internal committee structures of the organization, such as with the ethics committee.

Ethics in Health Leadership

The ethics committee has three main purposes: education, consultation, and policy review.

Challenges of the committee include internal organizational principle conflict, values contradiction, leadership team decision making, and community and industry ethical attitudinal changes.

The health organization should have an individual appointed on staff as the resident ethicist to assist in decision and policy making.

The establishment of an ethics committee that meets on a regular and reoccurring basis can likewise keep the leadership informed of relevant and legitimate issues confronting the health organization.

Ethics in Health Leadership

Example: When Actions and Ethics Collide

During the financial collapse of many American based organizations in the fall of 2008, Congress reacted by providing over $700 billion dollars to organizations that had run themselves into the ground through bad business practices and risky financial behaviors. However, it was later learned that the CEOs of many of these financially insoluble organizations were still going to receive annual bonus checks up to $620,000.

Ethics in Health Leadership

Common Ethical Dilemmas in Health Organizations

Ethical dilemmas in health organizations generally arise out of professional or values-based, conflicts of interest.

According to the American College of Healthcare Executives, a conflict of interest occurs when one has conflicting duties or responsibilities and meeting one of them makes it impossible to meet the other. The classic example occurs when a decision maker for one organization is also a decision maker or influence for another organization with which business is transacted.

Ethics in Health Leadership

Relationship Morality

Ethical dilemmas in the health organization are inevitable. In the field of health leadership, ethical dilemmas occur at three levels: micro, macro and meso.

The micro level involves individual issues, such as relationships between individuals and leaders.

The meso level involves organizational or professional issues.

The macro level involves societal or community issues which reflect governmental actions or social policies. These are typically culturally based.

Ethics in Health Leadership

Business and Financial Ethics

Contracts and Negotiations

Ethics in Health Leadership

To embed the ethical foundation and moral actions, what systems need to be in place, such as committees, policies, procedures, enforcement of those policies and procedures (consider coupling, should it be tight or loose regarding ethical frameworks and moral behavior and actions?), and leadership role modeling considering customers/patients expectations, business conduct and operations, negotiations, contract agreements and compliance, legal/regulation compliance, error remediation (how do you resolve errors made?), and health service and/or product delivery?

How can leadership decisions remain consistent to the ethical framework over time? How do you know you are consistent?

Ethics in Health Leadership

How can organizational culture incorporate the ethical framework and moral application of principles the health organization holds important?

How does the health organization integrate its ethical framework and moral applications into its strategic planning, decision-making and daily operations?

Ethics in Health Leadership

How does the health organization communicate its ethical framework and moral application into the communities they serve and to the interface and external stakeholders of the health organization?

How does the health organization ensure internal staff and subordinate adaptation to the ethical framework and moral application of that framework to long term (training, annual updates, rewards and punishments, etc…) employees and to new employees (orientation, training, etc…)?

Ethics in Health Leadership

Who keeps the health leadership team accountable to the ethical framework and moral application of established principles?

Is the ethical framework and moral application of those principles reasonable, relevant and realistic? How are boundaries established?

Ethics in Health Leadership

Who (individuals, groups, legal counsel, etc…) has the authority to initiate an ethical incident report, an ethical discussion, an ethical incident investigation, an ethically attributed reward or punishment? Is the health organization legally or liability oriented to ethical considerations or leadership oriented or both (what may be legally ‘moral’ to limit liability may not be leadership ‘moral’ to do what is right)?

Ethics in Health Leadership

Right to Life

Roe v. Wade

Euthanasia

Understanding the Patient’s Spirituality Base in Decision Making

To adjust to the spiritual needs of patients entering the health system, leaders should strive to be aware of the diverse beliefs within their organizations and foster a high degree of sensitivity and respect for those beliefs.

Ethics in Health Leadership

Understanding the Patient’s Spirituality Base in Decision Making

Specific beliefs and practices to consider include, but are not be limited to:

Healing rituals;

Dying, death, and care of dead bodies;

Harvesting and transplanting organs;

End of life and right to life decisions; and

Use of reproductive technologies.

Ethics in Health Leadership

Common Ethical Codes Adopted by the Health Industry

Two of these theories are , contrasting frameworks,: Utilitarianism and Deontology.

Issues surrounding patient rights of autonomy, beneficence, non-malificence and justice important as well.

Common ethical codes or frameworks should be integrated with the cost, quality and access paradigm considering changes to the health system or resource allocation of health resources.

Ethics in Health Leadership

Autonomy, Beneficence, Non-maleficence and Justice

Autonomy: The patient's right to self governance and medical decision making;

Beneficence: The requirement of the health organization to do ‘good;’

Non-maleficence: The requirement for the health organization to do no harm; and

Justice: The obligation to give each patient fair resource allocation (services and products associated with the care process).

Ethics in Health Leadership

At the foundation of ethics is Distributive Justice.

Distributive Justice is a set of theories or ideologies that attempt to instill a set of values, ideals of fairness based on those values, and beliefs in the allocation of resources, food, water, housing, wealth/money, opportunities, materials, etc…, throughout a society.

Ethics in Health Leadership

At the foundation of ethics is Distributive Justice.

At its root, ethics is a framework that is based on a Distributive Justice theory or combination of those theories; ethics is an extension of resource allocation and the methods of that allocation while morality or morals is the level of congruence to that ethical framework.

Social Justice and Market Justice

Utilitarianism

Utilitarianism is a theory that takes as its primary aim the attainment of maximum possible happiness of a society as a whole. This goal is to be achieved in such a way that one first checks what makes every particular individual in a society happy, then sums up all these various wants and preferences, and finally finds out how to satisfy the greatest number of them.

Ethics in Health Leadership

Egalitarianism

Egalitarianism is a set of closely related theories that without exemption advocate the thesis that all members of a society should have exactly equal amount of resources.

Ethics in Health Leadership

Libertarianism

Libertarianism suggests that the market or market forces should determine the distribution of resources in a society.

Deontology

Deontology is the opposite of Utilitarianism. It is an ethical framework and philosophy of resource allocation that suggests actions should be judged right or wrong based on their own values and principle driven characteristics.

Ethics in Health Leadership

Pluralism

Pluralists hold that goods which are normally distributed in any society are too different to be distributed according to only one criterion. To almost every one of these various kinds of goods we should apply a criterion that is characteristic for it. Thus we have diverse spheres of justice in which there are different criteria that tell us which distributions are morally right.

Parking Lot Example

Ethics in Health Leadership

The Difference Between Medical Ethics, Clinical Ethics and Bioethics

Clinical ethics refers to the ethics of the clinical practice of medicine and with ethical problems that arise in the care of patients. This includes traditional professional medical ethics that places the patient at the center of consideration.

Ethics in Health Leadership

The Difference Between Medical Ethics, Clinical Ethics and Bioethics

Traditional medical ethics were deficient in the face of technological advances of recent years; this reality has giving rise to bioethics. Bioethics' first concern is with 'the intersection of ethics and the life sciences' and later expanded to include human values.

Ethics in Health Leadership

Health organizations have to balance and develop systems to adhere to medical and clinical ethical standards as well as bioethical standards.

Ethics in Health Leadership

Health Leaders Are Part Ethicist

Establishing and chartering ethics committees with authority;

Requiring staff attendance, participation and evaluating education programs;

System of policy development and review;

Seeking consultation by utilizing consultants with similar values and moral practices;

Integrating professional, clinical, and business ethical performance through leader role modeling and subordinate reinforcement (rewards and punishments);

Ethics in Health Leadership

Health Leaders Are Part Ethicist

Fostering a positive ethical climate within an open and supportive communication environment (for example, it is alright to tell leadership about a mistake of error); and

Reviewing relationships with external stakeholders, partners and entities with which the health organization has contract relationships to evaluate ethical framework and moral practice congruence with the health organization.

Ethics in Health Leadership

A Health Leader’s Challenge: Where to Start?

First, what values does the organization hold?

What Distributive Justice Theoretical framework should ethical decisions be based upon?

Does that framework apply to all situations and if not when does the framework not apply and what framework takes its place?

How do values of the health organization get put into practice?

Ethics in Health Leadership

A Health Leader’s Challenge: Where to Start?

How does a health organization establish an ethical framework and moral application of principles (planning, group discussions, professional associations, laws and regulations, community expectations, community needs, etc…)?

Does the health organization have an ethical statement or creed highly visible and accessible by all stakeholders?

Ethics in Health Leadership

Health Organization Corporate Regulatory Compliance

Much integrates with governmental payment (reimbursement with taxpayer funds) as part of fiduciary responsibility

Much deals with private/personal financial gain done outside the care process

How does the example organization create a system of regulatory compliance?

Ethics in Health Leadership

Define distributive justice, ethics, morals, values and conflict of interest. Can you describe how they are used by health leaders in decision making?

Explain four ethical principles that guide decision making associated with patient care. How can leaders use these principles in decision making with a health organization?

Discussion Questions

How could you apply at least two ethical frameworks/Distributive Justice Theories, with examples of moral practice of a leader, to an ethical issue in a health organization? What would be the results?

Should health leaders adopt Utilitarian and/or Deontological postures in their organization? How could you differentiate potential decisions leaders would make between the two frameworks?

Discussion Questions

What available options does a leader in a health organization have to develop an integrated system of ethics and moral practice? What would be the potential impact of each option regarding appropriate ethical adaptation across the organization?

How would the utilization of at least three different ethical frameworks (Distributive Justice Theories) react with regard to patient autonomy, beneficence, non-maleficence, and justice? How would the application of moral practice associated with those frameworks (at least three) be different for a Right to Life Issue and for the practice of Euthanasia?

Exercises

Define distributive justice, ethics, morals and values. Describe how they are used by leaders in decision making in one (1) page or less.

Explain four ethical principles that guide decision making associated with patient care in one (1) page or less.

Apply at least two ethical frameworks/Distributive Justice Theories, with examples of moral practice of a leader, to an ethical issue in a health organization in two (2) pages or less.

Exercises

Read the Case Study of the Transferred Employee below and answer the following questions in two to three (2 - 3) pages.

What do you do?

Do you change the documents?

Do you go back and confront your supervisor?

What is your decision and why did you make it?

What is your next course of action?

What other factors do you consider and what other actions do you take?

What ethical framework/Distributive Justice Theory best supports your decisions regarding the case and why?