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29 iStockphoto/Thinkstock The Health Care Profession and the Virtuous Professional 2 Learning Objectives 1. Identify the characteristics of a health care professional. 2. Understand the idea of virtue as a mechanism to demonstrate virtue and address ethical dilemmas. 3. Explore how virtues are necessary to cultivate good health care professionals and can be derived from an inquiry into the goals and ends of health care management and delivery. 4. Understand the strengths and weaknesses of virtue theory. 30 CHAPTER 2 Section 2.1 The Role of the Health Care Professional Almost 70 years ago, the World Health Organization defined health as a state of complete physi- cal, mental, and social well-being and not merely the absence of disease or infirmity (WHO, 1948).

Some criticize this definition as too broad and unhelpful for setting policy. However, the definition did point out the holistic qualities of good health and foretold the importance of considering all facets that contribute to well-being.

The primary goals of medicine are to restore and maintain health, comfort the sick and dying, and care for the patient. In Chapter 1 we reviewed ethical theories and discussed the rise of contem- porary methods such as principlism to address ethical problems. The oldest principle in medicine is “do no harm,” and that remains the general motto. However, questions about what constitutes harm and what constitutes benefit continue, and are further complicated with the choices posed by technological and medical advances. This chapter continues to address questions about the particular duties, rights, and responsibilities of those in the health care professions as they work to achieve the ends of medicine. We will consider the importance of virtue in the face of complex dilemmas and the ability to assess the relative weights of competing values and norms and choose prudently from among them.

2.1 The Role of the Health Care Professional I n general the roles of health care professionals require complex, analytic judgment. Because of the nature of their work, health care profession - als work with a good deal of autonomy. The social contract provides prestige, respect, and autonomy in return for placing the client or patient’s interests first. Health care practitioners typically have a sense of calling and a duty to share knowledge with others in the field. However, the professional relationships are role specific and require fidelity as well as trust and confidence. For example, physicians routinely see patients unclothed and hear their secrets, and must protect what they learn about their patients when in nonprofessional settings—it would be unethical for a physician to discuss at a social gathering his or her private, professional relationship to a patient. Nurses also routinely touch patients in intimate ways as they work at the bedside, but they are constrained by the same ethical taboos. Requirements for confidentiality stem from a similar source.

Perhaps as much as any virtue, professional roles in health care require courage: The physician who will do what is medically appropriate despite the fear of being sued and the health care administrator who tells corporate administrators that cutbacks in nursing staff will jeopardize quality of care are but two examples of professionals who exhibit courage. Such virtue flows from the nature of the work and its goals. Fuse/Thinkstock The doctor-patient relationship requires a great deal of trust and confidence because doctors are routinely required to examine their patients intimately. 31 CHAPTER 2 Section 2.1 The Role of the Health Care Professional Evolving Roles Organizational structure, financing, and health care delivery have rapidly evolved in recent decades to meet the demands of new technologies, insurance systems, and regulations. Physicians are a prime example of health care professionals who are required to exhibit strength of character in the face of constant change. In addition to the urgency, stress, and demands of practicing medi- cine, physicians’ political, financial, and organizational lives have been turned around since the end of World War II, particularly within the past few decades. While technology has made health care more effective, it has also fostered specialization; particular procedures and specialized organ-specific knowledge and skills have become the standard of care. No one physician can mas- ter all of these highly specialized skills, techniques, and knowledge. As physicians became more specialized, they were less likely to serve as the traditional family doctor, and thus lost the long- standing familiarity with the patient that that role afforded. Technology also created unrealistic public expectations that health care could prevent or cure most if not all ills. Higher expectations and the diminished relationship with a family physician further increased liability and the number of malpractice suits. Together, all of these changes diminished physician satisfaction.

Similar changes have affected health care administrators and pose significant ethical challenges.

Until the 20th century, accountants, comptrollers, nurses, and officers in military hospitals per- formed many managerial tasks. But as technology (such as imaging machines and intensive care units) and advancements that allowed complex procedures (such as open-heart surgeries) became integrated into the system, health care delivery required more capital-intensive, complex organizations. Today, health administration is a profession in and of itself, and one of the many demands on administrators is to develop an ethical culture and become leaders with the highest ethical standards. With corporatization, integration, and new financing mechanisms, the demands on administrators to balance the business with the clinical aspects of care have demanded formal attention. The profession now has its own codes and texts on leadership and management. The good health care professional is not simply a business executive, though he or she may share many of the same job responsibilities and qualities necessary for success in this field. Neither should the good health care manager be confused with a physician or other health care professional, though they will share many of the same goals. Health care administration involves leading a success- ful and prosperous organization; it serves special functions that enable health care providers to perform their jobs successfully. This means that health care executives and leaders practice their profession in light of divided loyalties. The ethical health care leader must learn to deftly balance competing interests between the business and the clinic, as well as within the clinic, when there is competition for limited resources. There are always legitimate and appropriate concerns that tug from different and sometimes opposite directions.

The ends of medicine, or the essence of the pursuit of health care as an institution, are what Pellegrino and Thomasma (1993) have said are “ultimately the restoration or improvement of health and, more proximately, to heal, that is, to cure illness and disease or, when this is not possible, to care for and help the patient to live with residual pain, discomfort, or disability” (pp. 52–53). In achieving these ends, the professions that make up the broad field of health care also have their own proximate goals and competencies that allow proper and effective caring and treatment. The means by which to practice ethically should be considered in the context of the nature of the work. What qualities foster ethical conduct? What can guide health care profession - als toward ethical behavior? Given the nature of health care, the dramatic needs of the sick and injured, and the demands of the business, how can the administrator best find ethical guidance?

In attempting to answer these questions, many scholars and practitioners have turned to the importance of a virtuous character. 32 CHAPTER 2 Section 2.2 Virtue Ethics 2.2 Virtue Ethics A ncient Greek philosophers, most notably Aristotle (384–322 BCE), proposed virtue ethics as a practical philosophy aimed at bringing about the highest human flourishing. A relative contemporary of Aristotle, the Chinese philosopher Confucius (551–479 BCE) was among those who understood ethics to be a concern for developing good character in a person, from whom good actions would flow. These actions were good insofar as they corresponded with good characteristics like diligence, sincerity, kindness, and respect. Centuries later, philosopher Alasdair MacIntyre (2007) defined virtue as “an acquired human quality the possession and exercise of which tends to enable us to achieve those goods which are internal to practices and the lack of which effectively prevents us from achieving any such goods” (p. 191).

For these philosophers, virtues were those characteristics that lead to and constitute happy, flour - ishing human lives. Aristotle’s approach emphasized the need to cultivate the virtues that best lead to performing our functions well. In Nicomachean Ethics, Aristotle states that “every sort of expert knowledge and every inquiry, and similarly every action and undertaking, seems to seek some good” (Aristotle, Rowe, & Broadie, 2002, p. 95). A virtue was an “excellence,” and all ethics concerned excellence of character. While other moral theories and methods focus on the action, virtue ethics is concerned with character. Rather than asking about goals or duty, goodness in this philosophy concerns the individual and the society; the virtue-based approach is concerned with what kind of per- son one ought to be. Aristotle’s central question for how humans should live was tied to the threshold question of “what is the good of man?” Traits such as honesty, compassion, sincerity, fidel - ity, and courage are examples of virtues.

Given its preoccupation with how to live a good life and become a good person, virtue ethics is especially appropriate for health care practice in that professionals are required to promote human thriving and to act in the patient’s best interests.

In other words, virtuous behavior is nat - urally associated with good health care leadership and practice. Virtue Defined A virtue is a habit of character that must be cultivated over a lifetime and consists of a mean between two extremes relative to the particular individual (Aristotle et al., 2002). Every virtue lies somewhere on a continuum between two opposing poles: a deficiency of the trait on one hand and an excess of it on the other. For Aristotle, it was necessary to achieve moderation between the two excesses. He termed this balance the “golden mean.” An example of a golden mean might be courage, which would be the balance between rashness (the excess) and cowardice (the defi - ciency). According to Aristotle, the good person is one who habitually follows this golden mean. iStockphoto/Thinkstock Aristotle proposed virtue ethics, which focused on excellence of character rather than specific actions. 33 CHAPTER 2 Section 2.2 Virtue Ethics Figure 2.1: Virtue is a habit of character Various elements make up one’s character. How do these elements provide the foundation for ethical behaviors?

According to Aristotle, making good decisions is also dependent on cultivating excellences of char - acter, or virtues, which concern both educated understandings and phronesis or practical wisdom.

Virtues include not only behavior, but internal motivational dispositions to act (Figure 2.1). Both are required for ethical behavior by health care professionals. By considering the goals toward which medicine and health care aim, and to which we can all usually agree, Aristotle shows how to determine the appropriate goals of a health care professional.

Virtues that apply within and across both business and medicine are relevant throughout the system and within organizations. For example, prudence, integrity, honesty, stewardship, fidelity, and courage are consistent with the requirements of healing, curing, caring, and technical exper - tise. Trust and confidence are necessary for institutional and personal thriving, whether fostered among patients, clients, colleagues, or employees. To have confidence in the fidelity and compas - sion of others is necessary for successful relationships.

Revival of Virtue Ethics Alasdair MacIntyre, a Scottish Catholic moral philosopher, is probably the figure most responsible for the revival of virtue ethics in the second half of the 20th century. In his influential book After Virtue, MacIntyre (2007) launched a detailed and scathing attack on modern moral philosophy’s attempt to establish a justification for universal and inflexible principles of morality based on pure reason. He accused modern ethicists of engaging in fruitless debates about the rules of moral action while ignoring the questions of morality that had occupied humanity for most of its history.

In MacIntyre’s opinion, by disengaging from human life as it is lived and treating ethics without context, modern ethics loses sight of the ultimate ends (telos) of human life and of the virtues necessary to achieve it. MacIntyre pushed ethicists to return to Aristotelian virtue ethics and refo - cus their attention on the traits, or virtues, that help make us good human beings, as well as the nature of the good life. 34 CHAPTER 2 Section 2.2 Virtue Ethics MacIntyre’s brand of virtue ethics is particularly pertinent to health care because he focused on characteristics that enable practitioners to achieve the goods that are central and internal to pro- fessions and practices. For example, patient health and well-being are goods that are central and internal to the practice of medicine, while goods like money and prestige are external to it. In order to be a good health care practitioner, the professional would need to embody qualities that enabled him or her to foster the health and well-being of his or her patients. Money and prestige might be incidentally received along the way, but they cannot be a good physician’s primary aims.

Are Organizations Moral Agents?

Boyle, DuBose, Ellingson, Guinn, and McCurdy (2001) have asked if organizations can be moral agents. Certainly, individuals within these organizations have moral lives. However, health care organizations also have their own moral ecology. Their perspective depends on their structure as well as their mission and moral viewpoints. Whether religious or secular, for profit or not, stand- alone or affiliated, all institutions share common moral demands. Boyle et al. (2001) state:Moral norms can be glimpsed throughout the organization. Norms are manifest in an organization’s formal structure, in its mission statement; policies and pro- cedures; codes of professional conduct; strategic objectives; business plan; and contracts with employees, vendors, and purchasers. Organizational moral norms are less clearly seen, but no less palpable, in the organizational culture (which includes informal policies and procedures) and in the gap between what is for - mally expected and the way things really get done.

Thus, it is important to recognize that organizations are, indeed, moral agents with responsibilities for ethical conduct.

Ethical Responsibilities of the Organization Not all virtues are required of or expressed by all health care organizations; however, some vir - tues are essential. All health care organizations serve persons who are vulnerable, dependent on care, and expect compassion and beneficence; however, all such organizations are businesses of some type. For-profit facilities will have mission statements that reflect their responsibility to shareholders to reinvest back into the facility. Yet even not-for-profit religious hospital leaders have been known to embrace the saying “no margin, no mission.” No matter their bottom line, all health care organizations are obligated to the same basic ethical requirements, accreditation, and governmental regulations.

Shared Ethical Responsibilities of Organizations and Practitioners Health care organizations are varied in the scope and range of services they provide, yet all share certain critical characteristics and moral responsibilities. For the purposes of developing a virtue ethic of health care, it is helpful to describe disparate health care agents (administrative officials, doctors, nurses) as having similar and critical overlapping ethical duties and responsibilities. Each responds to moral demands, professional relationships, and the excellences required to be a good health care leader or provider. Virtue ethics offers an answer to the question of what makes good health care leaders. 35 CHAPTER 2 Section 2.3 Values Indeed, texts on leadership for health care professionals advocate modeling the way, inspiring a shared vision, and encouraging the heart, along with other virtues such as selflessness and trust- worthiness (Rubino, Esparza, & Chassiakos, 2013). This approach has the advantage of deriving health care leaders’ ethical obligations and duties from their real clinical and administrative set - tings. It reverses the usual flow of health care ethics, which applies our already formulated ethical theory such as the utilitarian or deontological models from the top down. This direction originates in and derives from the practice of health care.

Many virtue ethicists such as Aristotle and Alasdair MacIntyre have used medicine as an example of a practice where lofty ends must guide action. Additionally, in order to be considered an excellent practitioner, the professional must also focus primarily on the goals of medicine. How - ever, the ends of health care administration are not identical to those of the clinic in general.

Administrators manage both the clinical and the business demands of health care. Delving into the question of what characteristics are salient, it is useful to look further at Aristotle’s vision of virtue ethics.

2.3 Values V alues generally denote worth. They have to do with things that are desired; people want to have, get, or do what is of value. Some things are valuable in and of themselves; they are said to have intrinsic value. Others have negative value in that they are things most people wish to avoid or prevent. Immanuel Kant is the most famous philosopher to put forth the view that persons have intrinsic value: They are worthy of respect (valued). Moral values are basic vir - tues, recognized across time and place. These qualities of character are considered necessary for a thriving society. Indeed, some contemporary scholars argue that we would die out as a species if we did not cooperate in the most basic, virtuous ways. At the very least we would fail to thrive (for example, see Edward O. Wilson, 1975, as one of the early proponents).

Just as every decision in health care involves ethics, they also involve values. These are not neces- sarily problems or dilemmas, but choices we make that reflect what matters to us and to others.

From this perspective, it is difficult to think of any decision or issue that is not defined at its core by values—by beliefs of what is worthwhile, desirable, or important for the issue at hand. Since infor - mation and decisions are health care’s primary products, it is important to examine the values that support our decisions and consider whether they are conducive to cultivating good health care in the clinic and in the organization.

Aristotle thought that the supreme good, or the ultimate goal toward which everything aims, is directly tied to the proper and unique functioning of the person or thing. He termed the excel- lence in the proper functioning of the person or thing arete, or “virtue.” Moral virtue for Aristotle is that which is conducive to people achieving the supreme good. In Aristotle’s view, a human’s unique function is to reason well. Therefore, attaining excellence in reasoning would lead to the supreme good for a person.

Meaning involves implicit and explicit valuation. In the culmination of his life’s work, Meaning, philosopher Michael Polanyi, with the help of Harry Prosch (1977), observed that reasoning—in everything from language formation by infants to philosophers’ treatises—involves attempts to create, reflect on, and communicate meaning, to assign or communicate value. We create mean- ing by reason; that is, by ordering the data received from our senses in ways that make it intel- ligible. We are always and forever privileging some data, senses, and interpretations over others. 36 CHAPTER 2 Section 2.3 Values Valued Health Care Virtues If it is true that we incessantly evaluate the world, how can we go about picking out what values inspire and energize our actions? More importantly, from the vantage of this textbook, how might we go about discerning which values should be the ones to inform our decision making in health care? Next, we will examine many of the values that the good health care professional possesses.

We will also discuss how one must be willing to be virtuous in the face of obstacles as a precondi- tion to ethical conduct.

Courage Courage is a virtue on which other virtues can be built. Courage ( andreia), like other Aristotelian excellences, is the prudent balancing between two extremes, namely, the deficiency of cowardliness and the excess of foolhardiness. We have been brought up to believe that one cannot be too courageous in the face of danger; however, Aristotle noted that in situations that are fearsome, it would be inappropri - ate not to be fearful, and thus it is fitting to act cau - tiously. In such a case, brash conduct accomplishes nothing or even makes things worse; it would be fool - ish to rush headlong into insurmountable odds. At the opposite end of the spectrum, a coward will fail to stand up for what is right on occasions when it is fitting. The courageous person, however, will appro - priately and reasonably assess danger and act as the situation demands.

The character (ethos) excellence of courage is acquired by practicing acting in courageous ways. Good health care professionals will act with appropriate courage given the situation. Acting courageously may involve undertaking difficult actions or facing the potential for unwanted consequences or unpleasantness, and is not only required in dangerous situations. Physicians exercise courage in giving patients and fami- lies bad news as well as in highly charged dramatic situations, such as emergency surgery.

Practical Wisdom, or Phronesis Practical wisdom is the faculty necessary to consistently or habitually make decisions well. To many, the term practical wisdom may sound contradictory. After all, isn’t practical the antithesis of theoretical? Plato (428–348 BCE) believed that wisdom was confined to the abstract and theo - retical, and that only a few privileged scholars might ever come close to it. Plato’s pupil Aristotle, on the other hand, disagreed with his teacher. Aristotle’s notion of practical wisdom was the cen- terpiece for his book Nicomachean Ethics, in which he wrote, “Wisdom produces happiness, not as medical science produces health, but as healthiness is the cause of health” (Aristotle et al., 2002, p. xii). Unlike many other treatises on ethics, Aristotle’s book was not about postulating rules or rigid frameworks for deciding how a particular action is right or wrong. Instead, it was concerned with the nuanced decision making necessary for doing the right thing in specific circumstances.

For Aristotle, phronesis, or practical wisdom, was the intellectual virtue that had a direct bearing on human conduct and required excellence in deliberation and appreciation of the goal as well as the likely outcome, which he called the practice’s telos (Sisko, 1996). Ingram Publishing/Thinkstock Health care professionals must be courageous to accomplish what needs to be done in the face of adversity. 37 CHAPTER 2 Section 2.3 Values Aristotle argued that phronesis was indicative of what health care providers do and is essential to ethical decision making (Aristotle et al., 2002). This is true because when confronted with complex situations that require action, the wise person does not merely apply a static set of ethical norms or principles to the dilemma. The wise health care leader will balance his or her experience and knowledge of the instrumental ends of the profession with the ultimate ends of medicine to judge the right course of action. Gadamer (1996) echoes this when he states that instead of merely being a matter of skill sets to master or competencies to accrue, medicine is more about “find- ing the right balance between our technical capacities and the need for responsible actions and choices” (pp. viii–ix). Aristotle believed that making the right choices, from the mundane to the important and complex, involved varying degrees of wisdom. For Aristotle, ethics did not consist of black-and-white rules inscribed in doctrines about good and bad, but rather was concerned with practical and specific questions about what people should do when faced with particular circumstances. According to Schwartz and Sharpe (2010):

The wisdom to answer such questions and to act rightly was distinctly practical, not theoretical. It depended on our ability to perceive the situation, to have the appropriate feelings or desires about it, to deliberate about what was appropriate in these circumstances, and to act. (p. 5) Health care professions and leadership require both virtuous behavior and a clear understanding of goals, principles, and precedent. Rigid codes of conduct have often failed, or been insufficient, for providing the kind of ethical guidance or the nuanced interpretation that everyday health care situations demand. Practitioners of complex professions, especially those like health care in which a practitioner may have divided loyalties and commitments, know that hard-and-fast rules tend to offer black-and-white answers, but the practice of medicine cannot be reduced to such dichoto- mies. Very few rules are able to adequately encompass the kind of decision making called for in medical dilemmas, which usually do not involve decisions between what is obviously right and what is obviously wrong (these kinds of questions could hardly be considered dilemmas). Rather, such decision making features hard choices about which option is the best among the plausible, permissible alternatives. A daily rush of ethical challenges in a health care setting may include limited resources, staff that have their own ethical agendas, and patients who choose to override professional recommendations. Health care service providers have to balance the need to respect patient autonomy with that of providers. These are the kinds of fine distinctions that constitute a significant portion of problem solving for health care professionals; they must therefore resist one-size-fits-all decision-making models or pat answers. What is required, instead, is to consis - tently act wisely in practical situations, hence the term practical wisdom.

Fiduciary Duty In The Encyclopedia of Ethics , Sarah Williams Holtman (2010), a philosophy professor at the Uni- versity of Minnesota, offers the following definition for fiduciary duty :

Broadly speaking, we may term fiduciary any relationship in which one party trusts, relies or depends on another’s judgment or counsel. But we use the term, which originates in Roman law, especially to mark relationships where one acts on another’s behalf, as though the other’s INTERESTS were one’s own.

In a fiduciary relationship, the interests of the beneficiary should supersede those of the trustee.

The health care professional’s fiduciary duty involves acting in the patient’s best interests rather than his or her own. Indeed, this duty is central to the role of the health care professional, and it helps illuminate the moral outrage when someone is violated by a professional. Any breach of this 38 CHAPTER 2 Section 2.3 Values fiduciary duty—for instance, when a patient’s care plan is crafted for personal or professional gain instead of in the interest of the patient’s health—is seen as a selfish betrayal of the trust upon which the health care professional/patient relationship exists.

In a fiduciary relationship, discretion and the potential exercise of expertise are substantial. Such relationships have uneven levels of power and vulnerability. Patients are especially vulnerable; families are also dependent on the health care professional when a loved one is seriously ill.

Even when patients are fully competent, awake, and alert, they lack information, knowledge, and control. When patients are ill, injured, or otherwise dependent on the health care system, the fiduciary duties of health care professionals underscore the importance of trust, confidence, and commitment.

The concept of fiduciary duty is one that is shared by both health care ethics and the law, espe- cially the law of trusts. Legal trusts are instruments by which valuable property is delegated to an individual who can be trusted to manage the property well—not for his or her own personal benefit or gain, but for that of third-party beneficiaries. In such cases the trustee (or manager of the property) has a legal and moral duty to do the best job possible with an eye toward the best interests of the beneficiaries. Borrowing from this same concept, Thomas Percival, the 18th- century English physician best known for having written the first modern medical ethics code, insisted that physicians remain faithful and dutiful as they ministered to the sick whose lives had been “committed to their charge” (as cited in Shale, 2012, p. 102). The ends of health care demand that patients be cared for to the best of the practitioner’s ability, with the resources available, and to the exclusion of other less weighty concerns. Viewing health care professionals as the “trust- ees” of patient interests is an apt metaphor to describe a situation in which a person who has the ability and expertise to manage these interests devotes his or her time and abilities to furthering and promoting those interests. While the current emphasis on patients’ rights appears to speak to the contrary, the dependency that many patients have on health care professionals and their expertise further cements the aptness of the metaphor without denying the importance of shared decision making along with patients’ rights and responsibilities. In practice, the difficult bound - aries between protecting the vulnerable and respecting their choices constitute many ongoing ethical dilemmas in the clinic and in administration.

The fiduciary duty of clinicians toward their patients is relatively unambiguous, and the clinician is expected to act with ultimate regard for the patient’s interests. The fiduciary duty of health care managers and administrators, however, is more complicated. The divided loyalties under which health care managers must work include loyalties both to patients who are the beneficiaries of care and to the organizations the managers oversee. These conflicts may appear to complicate the priority of fiduciary duty. The administrator’s job is to balance these competing interests. The situation is often further complicated when a corporation is involved, or when the organization is integrated horizontally with a facility that is similar in scope and level of services offered and/or vertically with one of higher-level acuity. Do ethical requirements change with profit status? Are they altered by state regulations, unionization, or other developments within the facility? Under - standing that the ultimate end of health care is patients’ welfare helps frame the questions of to whom health care administrators owe their primary fiduciary duty.

The availability of resources is one major limiting factor when acting in accordance with fiduciary duty. Another limiting factor is the fact that fiduciary duty extends to the patient population in addition to individual patients. What do managers owe persons who reside near the facility, and how far does the responsibility to serve extend? To the community at large? The uninsured? Con - temporary physicians have increasingly recognized their professional duties to public health as well 39 CHAPTER 2 Section 2.3 Values as to their individual patients. Health care professionals are concerned with the health and well- being of the entire population, which could potentially translate into individual patients’ interests sometimes bowing to the needs of other patients. These challenges require wisdom and then pol- icy, which can be difficult to craft in our pluralistic, diverse society. What is clear is that the fiduciary duty owed by health care professionals requires that patient interests come first (Shale, 2012). Case Study: Hidden Incentives On August 16, 2013, the Oregonian published a report of a case that demonstrated administrative, clinical, and entrepreneurial ethical problems. The following excerpts from that story make clear how important it is to get all relevant facts when an ethical decision is questioned.

The state recently completed a court case against two Salem doctors who put heart implants into patients without telling them that a manufacturer’s training program put a sales representative into the operating room. The DOJ [U.S. Department of Justice] accused the doctors in the civil case of having “misrepresented” their ser - vices as “for the exclusive benefit of the patient” and “concealing” from patients payments that created a potential “incentive” to use Biotronik implants—defibrilla - tors and pacemakers. The surgeons received between $400 and $1,250 for implant surgeries when a trainee was present.

Drug and device companies face increasing scrutiny over their payments to doctors, including speaking and consulting fees. But several experts say this is the first time doctors have faced state enforcement action for failing to tell patients about “actual or potential” conflicts that “should have been disclosed.” Experts say the Oregon case sends a message—but local providers are still trying to figure out what that message means. . . . At Biotronik’s U.S. headquarters. . ., presiden t Jake Langer called the state’s case unfair and detrimental to good health care. . . . Susan Chimonas of Columbia University’s Center on Medicine as a Profession said industry pay to doctors increasingly is online, but doctors should also disclose them to patients directly.

“A growing body of scientific evidence shows that even small industry payments can shape physicians’ treatment decisions,” she said. “If physicians want to maintain patients’ trust, then transparency is a minimum ethical requirement.”. . . Sales of heart implants have boomed over the last decade, and Biotronik, based in Germany, has gained ground on its three larger competitors. Several implant- makers have faced scrutiny over relations with physicians who use their products. . . . As far as whether the doctors should have informed the patients of the training pro - gram, Biotronik provided the Oregonian with an affidavit from Jonathan Moreno, a prominent University of Pennsylvania bioethics expert. He said there was no legal nor ethical reason to inform the patients of the payments and no basis for the state’s allegations against [cardiologists Kyong Turk and Matthew Fedor].

(continued) 40 CHAPTER 2 Section 2.3 Values Compassion In 1983 Pope John Paul II said, “None of the changes in society or the technology of medical care in recent times can alter the call the sick themselves press upon care givers so insistently. They call upon them as fellow caregivers in need” (cited in Thomasma, 2004). Thomasma (2004) reminds us that compassion is more than sympathy or pity; it transcends welfare and philanthropy.

It is the capacity to suffer, and suffer with, the sick person—to experience some- thing of the predicament of illness, its fears, anxieties, temptations, its assault on the whole person, the loss of freedom and dignity, the utter vulnerability, and the alienation every illness produces or portends. True compassion is more than feeling. It flows over in a willingness to help, to make some sacrifice, to go out of one’s way. . . . Compassion helps us to r ealize the human family. Case Study: Hidden Incentives (continued ) “No legislative or regulatory body has proposed, much less implemented, a require- ment that doctors make the kinds of disclosures the state of Oregon seeks to impose on Drs. Fedor and Turk,” he added.

Dr. Carl Elliott, a professor at the University of Minnesota Center for Bioethics doesn’t agree with Moreno’s analysis of when payments should be disclosed, saying the pay - ments create a potential conflict of interest. “You don’t need to be an ethicist to see that it’s wrong to take the money and hide that fact from your patients.” DOJ, for its part, says the case broke new legal ground. “We’re proud of it,” spokes- man Jeff Manning said. “We think it’s good for consumers that this kind of disclosure be made.” The biggest hospitals in Oregon don’t require doctors to tell patients of payments from device or drug makers. . . . A Salem Health spokesperson said doctors generally should be informing patients of outside payments and the health system plans to adopt a policy to make sure that happens. “Our board wants to have a policy to ensure that patients are fully informed of any relationships between physicians and drug and device manufactur - ers,” said Sherryll Hoar.

Biotronik’s Langer said he welcomes a federal law called the Sunshine Act that will make such payments public on a government website starting late next year. But he notes that health care is full of hidden incentives such as hospital profit-sharing with doctors: Should all incentives be disclosed to patients? He said Biotronik asked DOJ precisely what needs to be disclosed and the response was, “We don’t know exactly where the limits are.” (Budnick, 2013) Discussion Questions 1. What additional facts do you need to analyze the ethics of this case? 2. What principles and virtues do you look for? 3. What conclusions do you draw? Explain. Source: Nick Budnick. Oregon DOJ case means doctors could tell patients ties\ to drug, implant makers. The Oregonian (Aug 16, 2013). Retrieved from http://www.oregonlive.com/health/index.ssf/2013/08/oregon_case_suggests_patients.h\ tml .

While honesty involves truth, it does not require violation of confidentiality. Silence can indicate respect for others as well as promise keeping. For example, if someone has confided a vital per- sonal secret, the person confided in has a duty to keep silent. Honesty, respect, and promise keep- ing are critical, basic ethical duties. The health care system and the transactions that constitute competent care would be significantly jeopardized and even unimaginable without obedience to these virtues.

Fairness Fairness as a virtue applies to relationships between individuals and to resource allocation. In relationships, we have a duty to treat equal cases equally, that is, not to discriminate according to personal characteristics or other factors not immediately relevant to the situation. Indeed, fair - ness has been codified as justice and is one of the four basic ethical principles in health care (see Chapter 1). For the purposes of this discussion, fairness applies to the individual. Distributive jus - tice will be discussed in Chapter 8. One might contend that different degrees of compassion are required within specialties of medi- cine and/or depending on the particular health care profession. For example, does radiology require different compassion than family medicine? Is social work different from administration?

While there are differences in frequency, duration, and intensity of relationships, those distinc - tions do not diminish the importance or the requirement of compassion when working with per - sons in need.

Trustworthiness/Trust Trustworthiness is a critical virtue that extends beyond industry and profession. Hardin (2010) notes that in strong trust, the participants largely identify with each other, and people who see themselves as trustworthy are much more likely to behave accordingly. Communities, patients, and families are predisposed to trust health care professionals and organizations. On the indi - vidual level, trust is a prerequisite for sharing confidences, for taking an accurate medical history, or getting an honest narrative. In order to establish a strong trust, health care professionals and organizations must establish a reputation and, more importantly, a relationship. Case Study: Faith and Medicine A 90-year-old patient with advanced dementia is unable to respond physically or verbally. Her phy - sician notes she is anemic. He orders blood to be provided, but the nurse realizes the patient is a Jehovah’s Witness. Persons of this faith may not receive blood or blood products. The patient’s two children are not Jehovah’s Witnesses, and they say they do not care about her faith; they just want the blood administered.

Discussion Questions 1. What ethical virtues are at play for the nurse and the children? 2. How should the organization and medical staff approach this scenario? 42 CHAPTER 2 Section 2.3 Values Generosity/Openhandedness Openhandedness (eleutheriotes) is the name that Aristotle gave to the important virtue of pro- viding benefits to others, or what we might now call generosity. Strictly speaking, this is the excel- lence of character that exists on the continuum of giving and receiving material possessions and financial wealth. Its deficiency goes by names such as greed or avarice, and its excess can be called profligacy, which involves excessive spending that is imprudent, wasteful, and unsustainable. This type of behavior decreases the ability to give appropriately, since it can lead to financial ruin.

In the context of health care professions, this virtue demands sufficient resources such as funding in order to further the ultimate goals of health care. This means that ethical health care organi - zations will not reap outsized rewards with the primary goal of building wealth or profit. Asset acquisition is necessary for an organization’s long-term success in caring for the sick and to con - tinually provide beneficial treatment and care to the poor and uninsured. It is important to keep profit margins in service to these greater goals, rather than to simply amass profits. The matter becomes more complicated as for-profit facilities and corporations compete or merge with not- for-profit facilities.

Integrity Boyle, DuBose, Ellingson, Guinn, and McCurdy (2001) define integrity as the personal commitment to be honest and trustworthy in demonstrating and evaluating how one balances discretion and control in relationships with others. Health care professionals who can successfully integrate all of the values and virtues into a coherent character have the kind of integrity that helps them judge the relative importance of the myriad virtues, rules, principles, and interests they will encounter in reaching prudent and well-reasoned decisions. In addition to being a prudent decision maker, one of the most appealing facets of leaders with integrity is that they can be counted on to make these judgments consistently align with the primary ends of medicine, tempered by the secondary goals of their profession.

In addition to being a virtue itself, integrity was defined by Aristotle as the balancing of all the other virtues into a mean between extremes, which characterizes ideal moral wholeness. Integ- rity, like any other virtue, is cultivated through practice and habit formation. The novice leader must consciously act with integrity even on those occasions when internal conflict and uncertainty make acting this way difficult. With time and practice, acting with integrity gradually becomes sec- ond nature (and, in a sense, no longer “acting”). This is a sign that the virtue has become an indel - ible and enduring part of the person’s character. The health care manager who can be counted on to wisely assess the relative merits and competing values and interests of various stakeholders has achieved that reflective capacity and wholeness of moral character known as integrity. 43 CHAPTER 2 Section 2.3 Values A modern connotation of integrity is when people are steadfast in remaining true to their values, conscience, stances, or decisions. This is also a useful concept for the virtuous health care leader.

The ability to unflinchingly maintain one’s ideals even in the face of opposition, unpopularity, or pressure is another hallmark of a leader with integrity. Note that for a health care professional working in a facility whose policies violate their own conscience, the person must sometimes choose to obey conscience or leave the organization. For example, states recognize the right of Catholic hospitals to prohibit elective abortion or refuse to sterilize a woman after a cesarean section delivery. If a nurse has a strong moral objection to the policies, he or she has to decide whether to comply or quit. Strong moral conviction may also cause a pharmacist to refuse to stock or fill a prescription for the morning-after pill, as noted in Chapter 1. It is critical that people in health care professions be clear about their own values and then behave with integrity toward their conscience and within the organization. Some policies respect providers’ rights to demur, but that may be limited by the particular circumstance. A potential ethical conflict arises when there are no other options available to patients in need.

Three Interpersonal and Social Virtues Not all of the virtues that Aristotle dealt with could be considered lofty. Aristotle recognized there were some social excellences that helped to define the good person (Table 2.1).

Pleasing Others The first of these, which Aristotle fails to name explicitly, has to do with social grace. In pleasing others, good leaders must be careful to keep from being unnecessarily contentious and argumen- tative; they must also be careful not to be overly ingratiating. Leaders whose primary goal is to be liked are not necessarily effective. At some point, their courage, trustworthiness, and other virtues will be tested. Case Study: New Leadership A 200-bed acute care hospital located in the suburbs of a large city has an excellent medical staff and a diverse mix of patients. The hospital has been part of a for-profit corporation that respects the par- ticular needs of this facility. Abruptly, the facility is purchased by a Catholic health care system. The system changes the mission, installs new electronic and other desired technology, and discontinues all assisted reproduction technologies. It also prohibits prescribing contraceptives in the hospital and in the physicians’ offices located on campus. The gynecologists and obstetricians are outraged. They consider this a violation of their autonomy and professional rights. A group of women lawyers meet with the CEO, who explains the legal rights of organizations to comply with the religious tenets of the corporation. The physicians claim they cannot relocate without very high expense and probably loss of patients.

Discussion Questions 1. What are the ethical questions? 2. How would the four principles of health care ethics help to analyze the case? 44 CHAPTER 2 Section 2.4 Strengths and Weaknesses of Virtue Theory Design Pics/SuperStock One criticism of virtue theory is that the expectations of virtue can vary by culture. Presentation Confidence in self-presentation is the social grace that shows a rightful valuation of the self. Good leaders must be confident and steadfast in the face of trouble and indecision. When done appro- priately, this not only ensures that the organization will have decisive action when necessary, it also spurs others to be confident and value their contributions appropriately. The deficiency of this virtue is self-deprecation, a quality that does not inspire confidence in followers. The excess is ostentatious boasting and arrogance, which breeds contempt and disloyalty. Note that modesty has long been recognized as a virtue.

Relaxation Aristotle says of amusement and relaxation, “Here too is a way of interacting with others that is fitting” (Aristotle et al., 2002, p. 8). No one likes the excessively stiff and humorless leader who exudes tension and rigidity. However, as with the social virtues, extremes are not desirable and may discourage confidence among staff. Being what Aristotle termed “witty” will mean allowing oneself to be relaxed enough to foster an appropriate sense of ease and humor in others, while also knowing when seriousness and productivity are in order.

Table 2.1: Pitfalls of the three interpersonal and social virtues Virtues Pitfalls Pleasing others Looking to be liked instead of leading Presentation Self-deprecation, which reduces confidence Relaxation Too relaxed may discourage confidence 2.4 Strengths and Weaknesses of Virtue Theory S ome critics argue that the process of applying virtue theory—which includes the ability to perceive a situation, have appropriate feelings, and deliberate—is insufficient and lacking in guidance about how to implement the theory. Supporters of virtue ethics respond in several ways, as explained below.

Supporters of virtue theory contend that it is important to note the relationship between virtue and principles, which are fundamental guidelines that provide standards. Scholars accept the impor - tance of the principles and structure underlying virtue. Thomasma (2004) states, “Continued thinking about the relation of the virtues to more objective 45 CHAPTER 2 Section 2.5 Chapter Highlights standards is needed. . . . The r elation of virtue theory to narrative ethics is only intuitively rec - ognized as yet and has not been thoroughly explored.” Finally, he points to cultural differences, which include different expectations and confusion about the virtuous life. These concepts require further exploration.

Thomasma (2004) notes that virtue may impinge “not only on the physician’s self-interest, but also on the moral center of professional life itself . . . (giv en) how variable can be the context in which the virtue of integrity, or any of the virtues, is practiced. That is why the standards provided by the principles are so important to virtue theory as well as the other theories of medical ethics.” 2.5 Chapter Highlights • The professions are characterized by the complexity of their work and the associated autonomy. In return for the autonomy and prestige, the professionals working in these occupations promise to act in the best interest of their patients and clients. • The goals of medicine and the personal characteristics necessary for excellent practice must be considered in discussing what qualities are necessary for an ethical health care professional. • The primary ends of health care delivery are healing and caring for sick or injured patients and for fostering well-being. • The qualities that contribute to the character of a good health care practitioner are called virtues. • Virtues such as courage, integrity, compassion and practical wisdom are essential. • Individual practitioners may experience conflict between self-interest and the needs of patients/clients in the work. • Integrity requires great strength of character. Case Study: Examining Virtue Pick from Table 2.2 two virtues that you believe are important for health care leaders. Using the form in Table 2.3 as a template, write down the virtue in the first column. Then, in your own words, describe what you think that virtue consists of in the second column. Since Aristotle conceived of virtues as the attainment of a golden mean somewhere between two poles, fill in the next two columns with what you believe is the excess of the virtue as well as the deficiency of the virtue (or its “defect”). For the last column, think of either a hypothetical or a real-life example of a health care leader who can serve as a “moral exemplar” of this virtue. You can choose an example of someone who either embodies the attainment of the virtue or golden mean, or someone who fails to do so. Make sure to describe exactly what makes this individual succeed or fail to be virtuous.

(continued) 46 CHAPTER 2 Section 2.5 Chapter Highlights Case Study: Examining Virtue (continued) Table 2.3: Sample virtues for health care leaders Aesthetic virtues Economic virtuesInstitutional virtues • Beauty • Creativity • Coherence • Elegance • Profitability • Efficiency • Frugality • Ingenuity • Quality • Professionalism • Safety • Collaboration Legal virtues Moral virtuesPersonal virtues • Justice • Equality • Freedom • Order • Respect • Empathy • Beneficence • Honesty • Integrity • Happiness • Reliability • Courage Religious virtues Scientific virtuesSocial virtues • Benevolence • Fidelity • Compassion • Forgiveness • Knowledge • Objectivity • Curiosity • Discipline • Stability • Community • Responsibility • Loyalty Submission Template Here is a sample form that’s been filled out for the virtue “integrity.” VirtueIntegrity Description A virtue in which a person exhibits unity of character manifested in “holding together” even in the face of strong disruptive pressures or temptations.

Excess Rigidity: “sticking to one’s guns” even when one is obviously wrong.

Defect Wantonness: exhibiting no stability or consistency of character.

Obstacles to the virtue in professional practice Individual corruption: individuals can be tempted by greed toward divisive defect. Lack of moral courage can also move one to both extremes.

Institutional corruption: one may work in an organization where corruption is the norm.

Moral exemplar (can be good or bad) A public health official who releases controversial scientific data of a health risk is not as bad as once thought, even though he or she may face pressure from the public health community and decreased funding. 47 CHAPTER 2 Section 2.5 Chapter Highlights Critical Thinking and Discussion Questions 1. Explain how and why a health care executive might act when confronted by the follow- ing dilemmas depending on whether he sees his job as either (a) being merely a business executive concerned with profits or (b) being a health care executive whose responsibil - ity is to lead a health care organization that sustains healing and health improvement.

a. The immediate health c are needs of the community you have traditionally served are going unanswered and provide only slim profit margins, but building a high-tech facility will appeal to richer clientele from the suburbs while earning you a big raise. b. After hiring a star surgeon who is proving to be very profitable for the surgical unit you manage, you start receiving complaints from staff, employees, and patients about his abusive bedside manner and his cruelty to anyone who crosses him. 2. Name a virtue not covered in this chapter that you think is important for a good health care leader to have. Explain why this virtue is important for health care administrators to possess and whether it complies with Aristotle’s “golden mean” standard. Name the virtue’s corresponding defect (having too little of the virtue) as well as its excess (having too much of the characteristic).

a. Why is this virtue important for health care administrators? b. Can it be expressed as a “ golden mean” between two immoral extremes? If so, what is its corresponding defect? What is its corresponding excess? 3. The ends of health care administration are not identical to those of the clinic. Adminis - trators manage both the clinical and the business demands of health care. How is the telos of health care administration different than the telos of medicine? What changes in the system have impinged on medicine? Do you think that the divided loyalties under which health care managers must work make it difficult to discern what a good, ethical decision might be when values conflict? Why or why not? Key Terms arete Excellence in the proper functioning of a thing, or virtue. Aristotle thought that the “supreme good” or the ultimate goal at which everything (including man) aims is tied directly to the proper and unique functioning of the person or thing. Aristotle sees man’s unique function as reasoning well. Attaining excel- lence in reasoning would be the characteristic that will lead to the supreme good for man, Aristotle thought. compassion The essence of caring. It is required of all health care professionals and of all good persons. It is the capacity to suffer, and suffer with, the sick person. courage Like other Aristotelian excellences, courage is the prudent balancing between two extremes; namely, the defect of cowardliness and the excess of foolhardiness. ends of medicine According to Pellegrino and Thomasma, the ends of health care, or its telos, are to restore or improve health, cure illness and disease, and care for patients. fiduciary duty A duty that is commonly referred to as acting in the patient’s best inter - ests rather than the physician’s. health care administration The ends of health care administration are to lead and manage health care organizations to facilitate maximal healing and caring for the sick, prevent disease and illness, and improve health and well-being.

This is the general definition for the entire field, but any health care organization must have at least one of these aims among its pri - mary goals in order to qualify as a health care organization. 48 CHAPTER 2 Section 2.5 Chapter Highlights integrity The state of moral wholeness that occurs when the virtues are integrated appro- priately and harmoniously. openhandedness The name Aristotle gave to the important virtues of providing benefits to others. This is the excellence of character that exists on the continuum of giving and receiving material possessions and financial wealth. Its deficiency is greed and avarice. Excesses are profligate spending and waste. phronesis Practical wisdom. telos The end or goal to which all people and practices aim. virtues Excellences of character. Moral virtue for Aristotle is that which is conducive to man achieving the supreme good.