Foundations and Essentials for the Doctor of Nursing Practice

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AMA Journal of Ethics® March 2020, Volume 22, Number 3: E183-186 FROM THE EDITOR Organizational Ethics for US Health Care Today Patrick S. Phelan Since the foundations of medical ethics were laid in antiquity, the practice of medicine has evolved in tandem with the landscape of health care systems. Humanity’s wealth of contemporary clinical knowledge is accompanied by profound complexity in our health care systems, where diverse types of organizations (eg, hospitals, insurance companies, government agencies, private health investment firms) play equally diverse roles in acquiring and mobilizing resources. The significance of this complexity for health care ethics has become a subject of increasing scholarly recognition and analysis. Indeed, the integration of clinical and business ethics has produced an amalgam known as “organizational ethics.”1 The interplay among hierarchy, management, and policy in current health care systems suggests that an organizational ethics lens is indispensable for appraising ethical problems.2 How should organizations maintain reasonable expectations of professional employees? How should they promote ethical conduct of their constituents? How should they foster public trust in science and practice? The contributions to this issue of the AMA Journal of Ethics address these and other timely concerns in modern health care systems and illustrate ways in which ethical questions are often inextricably bound with organizational constituents, cultures, and relationships. A fundamental difference between organizational ethics and traditional health care ethics is scope: traditional ethics focuses on individuals and organizational ethics on collectives.3 Relevant collectives in health care— including groups of clinicians, patients, nonclinical workers, administrators, and institutions themselves—have diverse and often overlapping memberships and interests that might conflict. Characterizing these collectives is a challenge: corporate organizations can be effective communities, and the aims of making profit and promoting public good can stem from a common purpose.4

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Types of membership in health care collectives are multifarious; some groups exist by virtue of a common profession or place of work, others are voluntary associations providing a cohesive group identity (eg, labor unions). Where union membership is an option for physicians in training, affiliation might suggest to some physicians’ ethically relevant and possibly conflicting interests and obligations, especially when collective action (eg, striking) is considered.5 Where clinicians are employees, organizational culture can be understood as expressing organizational values and establishing and enforcing organizational norms. Moreover, organizations’ goals for ethical conduct can be taken to reflect individuals’ particular ethical values.6 Organizations can communicate and propagate these values through mission statements, and such values can then be used to justify organizational goals or leveraged to manipulate constituent attitudes.7 For better or worse, organizations can establish employee responsibilities and norms of conduct as measures for ensuring compliance. Notions of transparency and trust surround relationships between health care organizations and outsiders. Contributions to this issue also address when— or whether—greater transparency begets greater trust8 and conflicts that can arise between a health care organization and an individual member.9 Institutional transparency and conflicts of interest can affect patients and constituents’ relationships—most importantly, those of clinicians and their patients.10,11 Health care organizations’ interests and their potential conflict with interests of others under their authority are of great ethical significance, as partiality can threaten fiduciary obligations clinicians owe to patients. Moreover, health care organizations’ interests can differ significantly from those of entities external to health care (eg, private equity firms).12 Given uncertain futures for health care systems, we should expect organizational considerations to be central in designing and delivering health care services. We can look to this issue for guidance about ensuring reasonable expectations of clinicians,13 responsibly navigating clinicians’ collective negotiations with employers,5 enabling justifiable adjudication of disciplinary action against organization members,14 maintaining cultures that discourage misconduct,15 sufficiently communicating and responsibly leveraging organizations’ aims to promote shared decision making,7 crafting solutions when there are few or no alternatives,9 and maintaining good public relations to foster trust.8

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References 1. Ozar D, Berg J, Werhane PH, Emanuel L. Organizational Ethics in

Health Care: Toward a Model for Ethical Decision Making by Provider Organizations. Chicago, IL: American Medical Association; 2000.

2. Potter RL. From clinical ethics to organizational ethics: the second stage of the evolution of bioethics. Bioethics Forum. 1996;12(2):3-12.

3. Pellegrino ED. The ethics of collective judgments in medicine and health care. J Med Philos. 1982;7(1):3-10.

4. McCrickerd J. Metaphors, models and organizational ethics in health care. J Med Ethics. 2000;26(5):340-345.

5. Howard D. What should physicians consider prior to unionizing? AMA J Ethics. 2020;22(3):E189-196.

6. Iltis AS. Organizational ethics and institutional integrity. HEC Forum. 2001;13(4):317-328.

7. Schueler KE, Stulberg DB. How should we judge whether and when mission statements are ethically deployed? AMA J Ethics. 2020;22(3):E235-243.

8. Cain DM, Banker M. Do conflict of interest disclosures facilitate public trust? AMA J Ethics. 2020;22(3):E228-234.

9. Kogan R, Kraschel KL, Haupt CE. Which legal approaches help limit harms to patients from clinicians’ conscience-based refusals? AMA J Ethics. 2020;22(3):205-212.

10. Levey NN. Medical professionalism and the future of public trust in physicians. JAMA. 2015;313(18):1827-1828.

11. Cigarroa FG, Masters BS, Sharphorn D. Institutional conflicts of interest and public trust. JAMA. 2018;320(22):2305-2306.

12. Casalino LP, Saiani R, Bhidya S, Khullar D, O’Donnell E. Private equity acquisition of physician practices. Ann Intern Med. 2019;170(2):114- 115.

13. Gunderman R. How should commerce and calling be balanced? AMA J Ethics. 2020;22(3):E183-188.

14. Tsan MF, Tsan GL. How should organizations respond to repeated noncompliance by prominent researchers? AMA J Ethics. 2020;22(3):E197-204.

15. Drabiak K, Wolfson J. What should health care organizations do to reduce billing fraud and abuse? AMA J Ethics. 2020;22(3):E217-227.

Patrick S. Phelan is a senior medical student at Washington University School of Medicine in St Louis, Missouri. He completed the requirements for the master of population health sciences (MPHS) degree in clinical epidemiology and will be awarded the MD and MPHS degrees in 2020. Outside of clinical

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medicine, Patrick’s academic interests include research methodology, biostatistics, and ethics.

Citation AMA J Ethics. 2020;22(3):E183-186.

DOI 10.1001/amajethics.2020.183.

Acknowledgements I am grateful to Dr Jay R. Malone for his guidance and support.

Conflict of Interest Disclosure The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.

Copyright 2020 American Medical Association. All rights reserved. ISSN 2376-6980