CASE STUDY PFIZER

HEALTH CARE MANAGEMENT ETHICS: BUSINESS ETHICS WITH A DIFFERENCE

Leonard J. Weber

Ethics in Health Services Management, Third Edition

. •; •' ' : ' : - ' " • , ' ' / • [ , . . . K u r t D a r r - '•:•. • \ - • • \ •••••;; '::"''^' •

Baltimore: Health Professions Press, 1997

While some of the ethical issues present in the business of health care and inthe management of health care institutions have been receiving attention recently, the attention is still somewhat scattered. Health care business ethics is not yet a well-developed field of research, education, and consultation.

Inspired, apparently, by the need to meet the recently developed organiza- tional ethics standards of the Joint Commission on the Accreditation of Health care Organizations, many health care institutions are now developing an "orga- nizational code of ethics." JCAHO requires that hospitals have and operate according to a code that identifies ethical practices (especially) in regard to mar- keting, admission, transfer, discharge, and billing. The code is meant to ensure that institutions conduct their patient care business "in an honest, decent, and proper manner."

The JCAHO requirement may also be the reason that many now use the term "organizational ethics" to describe the business and management side of health care ethics. It remains to be seen whether the consideration of "organizational ethics" in health care settings will be narrowly focused on meeting JCAHO's standards or whether it will provide the initiative for attending to other and broader issues. There are some indications that, at least among ethicists, "organizational ethics" will be much more extensive and inclusive than the JCAHO standards.^

In another example of an externally driven focus, much attention is also now being given to compliance programs. The federal government has put the con- trol of Medicare and Medicaid fraud and abuse high on the list of priorities and has provided health care institutions a strong incentive for putting compliance

©2000. Business Ethics Quarterly, Volume 10, Issue 4. ISSN 1052-150X. pp. 975-982

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programs in place: if such programs are in place, fines for infractions will be greatly reduced.

In some health care systems, ethicists have been now been assigned compli- ance responsibilities. This development may be significant in terms ofthe meaning of "ethics" in the management of health care organizations. It may be an occa- sion to promote a fuller sense of "integrity" in the organization^ or it may support a more minimalistic understanding of ethics as obeying the law. This, too, re- mains to be seen.

Many health care institutions have ethics committees in place. These multidisciplinary committees often have a predominance of clinical profession- als and their work until recently has focused almost exclusively on clinical ethical issues. They are now sometimes being turned to for assistance in addressing issues in organizational ethics. This is understandable, since such committees are a known focus for doing ethics in the institution. But, as I discuss below, doing organizational ethics out of the framework of medical ethics is not satis- factory and may provide a distorted understanding of the responsibilities of health care managers. Managing organizations is not the same as caring for individual patients. One of the major needs in health care ethics today is a more adequate development of concepts, approaches, priorities, and cases in addressing issues in organizational or management ethics.

Systematic overviews of health care organizational/business/management ethics are few, though it is not unusual for courses in ethics to be part of the curriculum of university programs in health care management or health care services. For years, when asked what text I recommend for such courses, I have given the best answer that I could: "None." Each ofthe few texts available needed to be so significantly supplemented that it was probably a better strategy to com- pile one's own set of readings (though this has also been difficult because ofthe limited nature ofthe literature). Now I have a different answer. I recommend the third edition of Darr's Ethics in Health Services Management.^

Darr's book is made up of five sections: I. Identifying and Solving Ethical Problems (Chapters 1-2) II. Guidelines in Making Ethical Decisions (Chapters 3-5) III. Administrative Ethical Issues (Chapters 6-8) IV. Biomedical Ethical Issues (Chapters 9-10) V. Emerging Ethical Issues (Chapters 11-13) The text includes 66 cases and vignettes. Rather than engaging in a careful critique of Ethics in Health Services Man-

agement, I attempt here to use Darr's work as a context to identify some of the general considerations that may be important for anyone promoting an under- standing of health care management ethics. I differ from Darr somewhat in regard to both the content and the organization of a systematic introduction to health care management ethics (some of these differences will be become clear), but his work does provide the opportunity to address most of the most important issues. This is a significant contribution.

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The Business of Health care

One of the most basic questions that needs to be reflected upon in any sys- tematic consideration of health care management ethics is the nature ofthe health care business. Darr is essentially correct, I think, in making the point that the health care industry is different from most other businesses in "purpose, type of service provided, orientation, and motives." (207) Health care organizations may or may not have non-profit status, but the orientation has been and should con- tinue to be humanitarian.

Both the public and health services professionals recognize, according to Darr, that "we have a higher calling, one going well beyond the bottom line. Codes of ethics assist in defining this calling and the duty of managers." (97) Health ser- vice organizations, he notes, "are social enterprises with an economic dimension rather than economic enterprises with a social dimension." (207)

Others have recognized differences between health care ethics and business ethics. Wicks and Glezen, for example, point out some of the differences be- tween resources available in bioethics consultation and in business ethics consultation.* Two ofthe differences they identify are particularly relevant here: 1) the clearly established moral traditions in medicine compared to the few in business; and 2) the socially recognized authoritative bodies (everything from the AMA to Presidential Bioethics Commissions) that help clarify ethical stan- dards in medicine and the lack of similar sources in business ethics. There is a long and strong tradition of the importance of ethics in health care, one that seems to be directly related to the focus on humanitarian service.

While Wicks and Glezen do not make the point, this explicit emphasis on ethical behavior is present in the management side of health care as well as in the clinical side. Health care management has long been recognized as a profes- sion in a way not found in the management of most other types of business organizations. The codes of ethics of two important professional associations of health care managers (the American College of Healthcare Executives and the American College of Healthcare Administrators) are found in the appendix of Ethics in Health Services Management. These codes reinforce the understand- ing that health care managers are professionals whose primary responsibility is to patients and to the community, not to owners or investors. As stated in the Preamble to the ACHE Code of Ethics:

"The fundamental objectives of the health care management profession are to enhance the overall quality of life, dignity, and well-being of every indi- vidual needing health care services; and to create a more equitable, accessible, effective, and efficient health care system."

Health care may be a business, but it is a business with a difference. I appreciate Darr's recognition of the importance of understanding the pro-

fessional nature of health care management, but I am somewhat disappointed that the point is not used as a starting point or as an organizing principle for the text (indeed, a casual reader might even miss the point, since it is not introduced

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early in the book and is not systematically developed). This professional orien- tation is much more central to understanding the ethical responsibilities of health care managers than the introductory discussion that is employed — a fairly stan- dard introduction to defining ethics and to differences among moral philosophies. What the profession is all about in the context of the contemporary health care system and of contemporary health care needs seems to me to be much more to the point of health care management ethics than the differences between utili- tarianism and deontology. Darr, of course, is not the only author about whom this point can be made.

I am also a little disappointed that Darr did not explore the ethical issues raised by for-profit health care services. He is very clear that "Managers' re- sponsibilities to the patients take precedence over their fiduciary responsibilities to their organizations." (2) This would seem to mean that, even in for-profit health care organizations, managers should be expected to subordinate the inter- ests of share-holders to the standards of the profession of health care management. The potential ethical stresses or dilemmas faced in for-profit health care man- agement merit attention and consideration that is not found in this book.

Management Ethics, Not Clinical Ethics

Darr's preferred ethical framework for managing health services is comprised of four principles: 1) respect for autonomy; 2) beneficence; 3) nonmaleficence; and 4) justice. These principles, articulated most fully by Beauchamp and Childress,^ are very well known in bioethics (where they are often referred to as the "Georgetown Mantra"). As they have been interpreted and applied during the last two to three decades of work in bioethics, they have been employed to resolve issues in clinical ethics, where key concerns have been confidentiality, informed consent, and the right to refuse treatment. The context has largely been the clinician-patient relationship and the emphasis has been primarily on the rights of individual patients. These four principles have been part of the context in which these rights have been asserted; the emphasis has clearly been on the autonomy principle.

In clinical ethics recently, there has been increased attention paid to the need to develop a more carefully nuanced understanding of patient autonomy. Com- petent patients clearly have a right to refuse unwanted treatment, but they do not have the same sort of right to get any treatment they want, regardless of whether it is medically indicated or an appropriate use of limited medical resources. The clinician has a professional responsibility to more than the individual patient as well as a responsibility to do only that which is considered good medicine. There is an increased emphasis on the ethical responsibility of clinicians to conserve resources. In James Sabin's words: "As a clinician I am dedicated to caring for my patients in a relationship of fidelity and, at the same time, to acting as a steward of society's resources."^

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The focus in health care ethics has gradually been shifting from the clinician- patient relationship to include a greater emphasis on the decisions made outside the clinical setting. Many of the decisions affecting health-related individual rights and the well-being of the public arc made not by clinicians but by those involved in the business or management side of health care and by those in- volved in the development, application, and promotion of new drugs and new technology. The issues of confidentiality and informed consent remain very im- portant, but in addressing the overall impact ofthe health care system on people's lives, one must also consider issues related to conflicts of interest, to benefits determination, to the allocation of resources, and to judgments about the appro- priate purposes of medicine. Understanding the significance of developments in managed care and in genetic research may be as important for addressing the ethical issues in health care as understanding the nature of the clinician-patient relationship.

As noted above, the health care ethics committees that are in existence in many institutions are, in almost every case, clinical ethics committees. They have served as an important resource in addressing ethical issues related to pa- tient care, most notably treatment decision making near the end of life. Typically, when difficult cases are brought to the committee for deliberation and assis- tance, much time is spent reviewing the medical condition, the patient's wishes (if known), and expected medical outcomes. Much of the focus is on what the patient wants or is said to want. Rarely does anyone even raise the issue of cost and appropriate use of limited resources as considerations that help to determine what is ethically appropriate. Clinical ethics has not seemed to place justice issues on a par with autonomy issues, at least not yet. (In the Georgetown Man- tra, justice is listed last.)

Management ethics must start with justice. As the above quotation from James Sabin indicates, even some clinicians recognize an ethical responsibility to con- cern themselves deliberately with the stewardship of resources. While the appropriateness of this concern for clinicians is sometimes debated, there can be little doubt that it is a primary responsibility of health care managers. To use available resources most effectively to achieve appropriate health care goals while respecting the rights of employees and other stakeholders is the manager's es- sential responsibility.

Most managers know that not every decision that reduces cost is the ethically responsible way to proceed. Most also agree that it is usually irresponsible for managers not to take cost considerations into account when making decisions, including decisions about services that could potentially benefit patients. Cost containment is an ethical value, not just a practical requirement. It is not the only value at stake in most decisions, however, and is not the only requirement of a good organization. A helpful text for health care managers is one that pro- vides a framework for determining when some other value takes priority over keeping cost down. James Sabin states that, "As a clinician I believe that it is

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ethically mandatory to recommend the least costly treatment unless I have sub- stantial evidence that a more costly intervention is likely to yield a superior outcome."'' Challenging health care managers to identify an equivalent principle and its implications could be an important part of assisting health care managers to understand their ethical responsibilities.

Being a good manager requires a practical and working ability to address a variety of justice issues. While Darr recognizes justice as one of the basic prin- ciples of ethics for health care managers, the meaning of justice merits much more practical clarification than he provides.

Thomas Schindler, corporate ethicist for Mercy Health Services, describes a health care organization as having "three distinctive but interrelated roles: it is caregiver; an employer; and a citizen."^ Darr focuses consistently on the role of the organization as caregiver. He is less satisfactory in assisting readers to un- derstand the ethical implications of being employers in the health care industry and in recognizing their responsibilities to the public.

Health Care Organization as Employer and as Citizen

Managers of all sorts struggle with the fairness issues related to employing and managing staff in the organization. There are ethical issues related to deter- mining fair wages or salaries, to making decisions about downsizing, to evaluating performance, to setting and attempting to meet diversity or affirmative action goals, to addressing grievances, to responding to unionizing efforts, to applying sexual harassment policies and procedures, to protecting employee privacy, etc. Managing personnel issues in a just manner is a central element in being an ethical manager.

Darr's chapter on "Ethical Issues regarding Organization and Staff focuses more on relationships with the governing body and with the medical staff than it does with the issues listed in the previous paragraph. It is true that these issues are not unique to health care, but I am disappointed in his omission. The course or other context in which this book is read may well be the only occasion for the reader to review ethical issues in management systematically. Furthermore, there are important personnel-related concerns that need to be addressed in most health care settings, concerns that are best addressed from a solid foundation in the ethics of personnel management. These include: concerns related to the power and income (and often gender) differences between different groups of profes- sionals who interact regularly; concerns related to employment and discipline practices when institutions establish policies prohibiting participation in certain legal procedures or services (assisted suicide may make this issue more complex than abortion has); concems related to responses to unionizing efforts in non- profit service organizations; concerns related to caring for patients who have strong convictions about which caregivers are acceptable (in terms of culture, race, gender). The last issue has, in my experience, presented the opportunity

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for a thorough discussion of the relationship between patient preference and patient comfort, on the one hand, and employee comfort and rights, on the other.'

To describe the health care organization as citizen is simply to recognize that it has a responsibility to promote the public good, particularly a responsibility to seek to improve the health status of the community. Acknowledging good citi- zenship as an important component of ethical health care management leads to a recognition of the importance of assessing the impact on the public of institu- tional or organizational policies and practices. It is not enough to be concerned about the impact of these policies and decisions on individuals directly served by the organization and on individuals within the organization. It is not enough to be a good caregiver and a good employer. One need also be socially responsible.

A recently initiated environmental health campaign, "Health Care Without Harm," has called attention to the type of social impact to which health care managers need to be sensitive, i" The coalition involved in this "campaign for environmentally responsible health care" is seeking action to reduce the amount of dioxin and mercury pollution that results from health care practices (dioxin is a human carcinogen and mercury is toxic to the central nervous system). A spe- cial concern is the incineration of medical waste (because dioxin is produced when waste containing chlorine is burned). Medical waste has increased enor- mously over the years, in part because of changing technologies and the use of more disposable items. In part, the increase has resulted from precautions taken to prevent the spread of infectious diseases. The campaign is urging managers to reduce environmental harm without endangering patients or staff — by finding alternatives to polyvinyl chloride (PVC) plastics and to mercury and by elimi- nating unnecessary incineration of waste.

It is interesting, but not surprising, that health care organizations apparently need to be pushed from the outside in order to attend more adequately to the impact of their own practices, even when the impact is so closely health-ielat^d. The ACHE Code clearly recognizes that health care managers have responsibili- ties to community and to society, but everyday work pressures and the natural emphasis on the well-being of the organization make it difficult for most man- agers even to understand what this means, let alone place a high priority on these responsibilities. Given this reality of life, it may take more than Darr's discussion of social responsibility (in the very last chapter and mostly limited to allocation of resource issues) to integrate the citizenship responsibility into the thinking of most health care managers.

A Developing Field

In the still largely undeveloped area of health care management ethics, Kurt Darr has been one of the major contributors over the years. The third edition of Ethics in Health Services Management is, in my mind, the best text available at the time of this writing.

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The interest in health care organizational and business ethics appears to be growing rapidly. We can expect to see several new book-length publications ap- pear in the next few years. As I have tried to highlight in this review article, health care business ethicists need to make a number of important decisions about how to structure the analysis and discussion of responsibilities. Much re- mains to be done. I look forward to Darr's fourth edition as well as to the contributions of others who will be heard from soon.

Notes

'See George Khushf, "Administrative and Organizational Ethics," HEC Forum, Decem- ber 1997; Leonard J. Weber, "Taking On Organizational Ethics," Health Progress, May/June 1997.

^See Lynn Sharp Paine, "Managing for Organizational Integrity," Harvard Business Re- view, March-April 1994.

3 Another text for consideration is John R. Griffith, The Moral Challenges of Health Care Management (Ann Arbor: Health Administration Press, 1993).

•*Andrew C. Wicks and Paul L. Glezen, "In Search of Experts: A Conception of Expertise for Business Ethics Consultation," Business Ethics Quarterly, January 1998, pp. 121-122.

'Tom L. Beauchamp and James F. Childress, Principles of Biomedical Ethics, 3d edition (New York: Oxford University Press, 1989).

*Sabin, James, "A Credo for Ethical Managed Care in Mental Health Practice," Hospital and Community Psychiatry, September 1994.

•'Ibid. 'Thomas Schindler, "Doing Justice," Unpublished. 'Leonard J. Weber, "The Race of the Care Giver: Should Managers Honor Patients' Re-

quests?" Health Progress, April 1995. '••Health Care Without Harm: The Campaign for Environmentally Responsible Health

Care. C/o CCHW Center for Health, Environment and Justice, Falls Church, VA.