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49 iStockphoto/Thinkstock Moral Identities and Organizations 3 Learning Objectives 1. Learn the importance of identifying and promoting core principles and values that both reflect an organization’s moral identity and provide a model to which to aspire. 2. Describe and differentiate between codes of conduct, values statements, vision statements, and mission statements. 3. Understand issues that arise in creating and implementing ethical statements. 4. Identify and understand the function of institutional structures that aim to foster and support an organization’s ethical mission. 50 CHAPTER 3 Section 3.1 Shaping an Entity’s Moral Identity In this chapter, we will examine the importance of shaping the moral identity of health care orga- nizations. In order to craft and articulate its moral identity, a health care organization must pur- posely reflect on its values.
There are four foundational documents health care organizations use to articulate and manage their moral identity: codes of conduct, values statements, vision statements, and mission state- ments. This chapter will explore the parameters of each of these documents, as well as how to create and implement them. We will also explore the core challenges that ethically admirable organizations must meet. Finally, we will examine some of the ethical dilemmas that led to the creation of committees designed to deal proactively, as well as reactively, with ethical issues that health care organizations face.
You will be asked to reflect on your own values and perspectives, and through exercises and ques- tions, you will be guided to articulate a personal moral vision or statement.
3.1 Shaping an Entity’ s Moral Identity I n the late 1990s a group of researchers from Harvard University and the National Institutes of Health conducted the BEST project, which stands for Best Ethical Strategies for managed care (Pearson, Sabin, & Emanuel, 2003). The goal of the project was to identify ethical excellence and how to perpetuate it. Their research found that an ethically admirable organization must meet three core challenges: 1. It must have a deeply held set of values that emphasizes care of the sick and promotion of health. 2. It must deal skillfully with the values conflicts that inevitably arise in health care. 3. It must make sure to live by its values.
These three core challenges were the basis for nine specific criteria that the researchers found recur in many exemplary health care organizations (Pearson et al., 2003). The nine criteria are outlined in Table 3.1. Table 3.1 Central ethical obligations for organizational ethics An exemplary ethical organization must:
1. Hold deeply a set of values emphasizing care of the sick and the promotion of health.
2. Involve key stakeholders in identifying its values and managing value conflicts.
3. State clearly and forcefully those values it commits itself to and guides itself by.
4. Disseminate understanding of its values to its entire staff.
5. Recognize that the full range of its activities influences the ethical quality of patient care.
6. Cultivate skill at identifying threats to and conflicts among its values.
7. Deliberate about value conflicts in light of what was done and learned in previous situations.
8. Ensure that it acts on its values: It “walks the walk” as well as “talks the talk.” 9. Partner only with others who live by compatible values.
Source: From Pearson, S.D., Sabin, J.E., & Emanuel, E.J. No margin, no missi\ on: Health-care organizations and the quest for ethical excellence (p. 33). Copyright © 2003 Oxford University Press. Repri\ nted by permission. 51 CHAPTER 3 Section 3.1 Shaping an Entity’s Moral Identity Many of these criteria correlate directly with the foundational documents that articulate and manage the moral identity of health care organizations. These are: codes of conduct, values state- ments, vision statements, and mission statements. Criteria 1, 2, and 3 highlight the necessity for articulating the organization’s values and making sure that these are aligned with the ultimate ends of medicine— care of the sick and the promotion of health. Criterion 4 shows the necessity of getting the staff and employees to understand the expressed values. The researchers also found that exemplary organizations not only made the staff aware of the values that undergirded the moral identity of the organization, but also helped individual members of care teams and staff feel that their work had meaning and therefore felt congruent with the values. In this way the organiza- tions could arguably be called cohesive cultural communities in which a culture of like-minded values and mission helped drive the work of the organization.
Criterion 5 serves as a confirmation of the necessity for the mission statement to be firmly grounded on and operationalize the values and vision of the health care organization. When these statements are consonant with each other, this interconnectedness results in day-to-day opera- tions being influenced by the deepest interests and commitments of the organizational culture.
Criterion 8 shows the importance of mission statements that are precise enough to truly guide a health care organization’s day-to-day actions and policies. The only way that health care organiza- tions can ensure that their staff and employees adhere to mission statements is to fight against the temptation to use lofty and vague language in the statements. Mission statements that con- tain such language, while perhaps being inspirational, are unhelpful at guiding action and behav - ior, as well as unhelpful at providing guidance for leadership to correct or even identify wayward conduct by employees and staff.
Meanwhile, criteria 6 and 7 show the importance of crafting values statements that, while articu- lating the values of the organization broadly enough to capture the ends of medicine, are spe- cific enough to alert leadership when two or more of these values will potentially be in conflict.
Doing this when first constructing an organization’s moral identity statements allows leadership to engage in preventive ethics by identifying conflicts and deliberating thoughtfully about them before they even arise.
The criteria stated in Table 3.1 therefore become a test for evaluating a mission statement’s con - tribution to the organization’s moral identity. iStockphoto/Thinkstock In shaping an entity’s moral identity, it is crucial to define the organization’s values clearly and communicate them effectively to the entire staff. 52 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct 3.2 Values, Vision, and Mission Statements and Codes of Conduct T his chapter will discuss and differentiate values, vision, and mission statements and codes of conduct. Under the banner of creating and maintaining change, this chapter will also discuss the critical duty that moral health care leaders have to keep an eye on whether these struc- tures, policies, and codes make sense. Values Statements Values statements are documents that attempt to identify an organization’s goals, principles, and commitments. The terms values statements , statements of philosophy, or guiding principles can be used interchangeably. What differenti- ates these from mission statements is that values statements define the moral bases upon which a health care organiza- tion operates. Values statements are the starting points from which the organiza- tion builds its moral identity as well as its practical procedures and processes.
This is not to say that health care orga- nizations that lack specific, articulated, and written values statements are rud- derless or lack a moral identity. In many cases these organizations may have underlying de facto values that help guide decision making and/or that emanate from the orga- nization’s aggregate decisions and orientations. However, if left unarticulated and undeveloped, these implicit values will often fail to helpfully guide action or provide the structure necessary for coherent moral identities. Health care organizations whose moral identities are indefinite and ill defined will foster an environment in which incoherent policies and even contradictory stances will be allowed to flourish. This will undermine the collective strength that comes from a unified mission.
Values statements can be concise and to the point, detailing relatively few overriding ethical val- ues or principles that function as a compass for the health care organization. This is the case with the values statement from Cottage Hospital in Woodsville, New Hampshire (2013):
Values Statement:
We value compassionate care, excellence, empathy, integrity, fiscal accountability, innovation, teamwork, responsibility. Used by permission of Cottage Hospital in Woodsville, New Hampshire. In the case of many other health care organizations, however, the values statement strives to be as complete as possible in its detailed description of the underlying values upon which the institu - tion rests. Age fotostock/SuperStock Through values, vision, and mission statements, as well as codes of conduct, a health care organization can set unifying standards and goals for itself, as well as establish its moral identity. 53 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct Many values statements include the value of innovation. Be aware that innovation by itself is ambiguous. It is important not to confuse the terms innovation or new with better. Innovations can be bad or not as good as what was already there. They may be exciting, however, for health care providers, consumers, and even granting agencies. One example is the underuse of equip - ment that comes about when competing facilities purchase technology in order to maintain the allegiance of their medical staff. A specific example of costly technology gone wrong was the 2002 plight of Cedars-Sinai Medical Center in Los Angeles; after years of development and spending $34 million, in response to significant criticism from the center’s medical staff the center pulled the plug on its health information system and started over with an off-the-shelf system.
Sutter Health, a vast network of hospitals and clinics based in California, highlights the following tenets in their values statement (Sutter Health, 2010):
Excellence and Quality - We exceed customer expectations by delivering premier clinical quality and maintaining the highest levels of safety.
Innovation - We continually create, seek out, and adopt new ways of providing value to our customers, rapidly moving from idea to execution.
Affordability - We deliver health care efficiently by using resources responsibly.
Teamwork - We recognize that the power of our combined efforts exceeds what we can accomplish individually, and we are accountable to each other and to our customers.
Compassion and Caring - We treat those we serve, and one another, with concern, kind - ness and respect.
Community - We work to understand and best serve the diverse needs of our communities.
Honesty and Integrity - We act openly and truthfully in everything we do.
One of Sutter Health’s stated values is that of innovation. Innovation is one of the most common values that health care organizations include in their values statements, with many also listing it as an element of their vision and mission statements. Progressing toward less invasive procedures, more affordable care, and cutting-edge technologies requires innovation.
Of course, all the values put forth by health care services or organizations will need to be specific so as to give a precise and accurate picture of that organization’s moral identity. In every case the values should serve as a basis for goal setting in the vision statement and be operationalized in the mission statement.
Vision Statements Vision statements are the inspirational and aspirational statements that define where the orga- nization is headed in terms of both actions and identity. Vision statements clarify what the orga - nization’s activities will consist of. Vision statements, therefore, rely heavily on values statements and differ from them (when they differ at all) in that vision statements tend to set their values and principles into the prescriptive mode of action. Vision statements anticipate some ideal state or role that the organization may have yet to achieve but toward which the organization aims to progress. They are thus forward-looking and future-anticipating statements. The best of these will be lofty enough to give the organization something to reach for and to be inspired by; they will also be realistically achievable and precise enough to be able to guide the agenda setting and operationalizing that needs to happen in the organization’s mission statement.
Some vision statements are concise and pragmatic, such as this one from Cottage Hospital in Woodsville, New Hampshire (2013): Used by permission of Sutter Health. 54 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct Vision:
To be the health care organization of choice for our service area.
Used by permission of Cottage Hospital in Woodsville, New Hampshire. Notice the difference in the language used here versus in Cottage Hospital’s values statement dis - cussed previously. It is true that Cottage Hospital’s (2013) values (“compassionate care, excellence, empathy, integrity, fiscal accountability, innovation, teamwork, responsibility”) can certainly be the compass that drives the hospital’s desire to be a leader in health services in its region. How - ever, the hospital’s vision statement more overtly outlines its future goals. The language chosen for its vision statement implies that excellence is akin to a competition in which there is a clear victor. Implying that health care is a competition may result in the wrong motivations or even a confusion of the ends of health care. On the other hand, the vision statement clearly identifies the patient as central to the organization’s success.
Other health care organizations strive to construct their vision statements to be more detailed descriptions of the underlying values upon which the institution rests. Based in Pennsylvania, Thomas Jefferson University Hospitals (2013) has articulated a more detailed vision of the health system it wishes to become:
Vision:
To be a national leader for excellence and innovation in the delivery of health care and patient safety, continually improving the quality of services and the patient care experience.
To be the model of service in our focused clinical service lines and in related patient-oriented research and clinical trials.
To provide exemplary clinical settings that support the education of future health care practitioners, both as individuals and as members of the collaborative health care delivery team.
To be an “employer of choice,” providing a highly rewarding environment for our employees. Used by permission of Thomas Jefferson University Hospitals, Pennsylvani\ a. Thomas Jefferson University Hospitals’ vision statement articulates service excellence, owner - ship, collaboration, and respect. Each value has a paragraph description. Notice how these values are carried forward to the vision statement. Other health care organizations may formulate their vision statements in a much more concise—yet still professional—manner. For example, Sutter Health (2010) has adopted a one-sentence vision statement that reflects its detailed values dis - cussed in the previous section:
Sutter Health leads to transformation of health care to achieve the highest levels of quality, access and affordability. Used by permission of Sutter Health. Likewise, the logos and mottoes of some health care organizations are arguably pithy vision state- ments of a sort. These slogans, many of which appear prominently in an organization’s advertising, 55 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct should be challenging to achieve. However, they should also attempt to be attainable and should send the message that with hard work, an organization can achieve or at least make progress toward its vision. Slogans such as “At X organization nothing is impossible” fail not only to give a specific vision for the organization, but also lead to possible misconceptions and unrealistic expec- tations that will be impossible for the institution to live up to.
The University of Texas MD Anderson Cancer Center in Houston, Texas, adopted the catchy and profound “Making Cancer History” slogan a few years ago. This three-word slogan contains a dou - ble entendre: Many of the treatment and research successes in the history of cancer care have occurred at this institution; the slogan can also be read as a rally cry to eradicate the scourge of cancer. This wording might be seen as just a clever advertising ploy, and certainly many might argue that it is in danger of fostering unrealistic expectations about a cure for cancer. However, others may see it as a concise and inspirational vision statement that orients the institution’s goal- setting mission, to which we now turn.
Mission Statements Note that values statements set the moral tone of the organization, whereas vision statements set the aspiration(s) of the organization. Mission statements, however, are documents that attempt to operationalize the goals set forth in vision statements; mission statements should reflect the underlying values articulated in the organization’s values statement. Values, vision, and mission statements, along with the code of conduct, serve to establish an organizational culture as well as define and control the organization. Mission statements will necessarily incorporate much of this description of the day-to-day work of the entity and provide enough specificity to be used as a mea - sure of whether particular actions or policies abide by and help achieve the organization’s mission.
In the University of Texas MD Anderson Cancer Center’s mission statement, there is a clear con - sonance with the underlying values the leadership of MD Anderson articulated for the institution.
The mission statement also flows logically and necessarily from its vision statement, of which “Making Cancer History” is a part:
The mission of The University of Texas MD Anderson Cancer Center is to eliminate cancer in Texas, the nation, and the world through outstanding programs that inte - grate patient care, research and prevention, and through education for undergrad - uate and graduate students, trainees, professionals, employees and the public. Used by permission of MD Anderson Cancer Center. Note that this mission statement operationalizes the vision and goes beyond patient care to make commitments to research and education.
Sometimes mission statements are short, practical affairs that describe in specific terms what it is the organization is doing, as in MD Anderson’s statement. In other cases the mission statement can incorporate much of the language from both the values statement and the vision statement to give a fuller description and understanding of not only what the organization does, but why it does these things and also how it will go about doing them. An example is the mission statement for Thomas Jefferson University Hospitals (2013) in Pennsylvania: 56 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct Mission Statement:
Thomas Jefferson University Hospitals are dedicated to improving the health of the communities we serve.
We are committed to:
• Setting the standard for excellence in the delivery of patient care, patient safety, and the quality of the health care experience • Providing exemplary clinical settings for educating the health care delivery profes - sionals who will form the collaborative health care delivery team of tomorrow • Leading in the introduction of innovative methodologies for health care delivery and quality improvement We accomplish our mission in partnership with Thomas Jefferson University and as a member of Jefferson Health System. Used by permission of Thomas Jefferson University Hospitals, Pennsylvani\ a. Note that vision statements, because they are aspirational, are generally more brief and memo- rable. Mission statements as the one above are looked to for guidance and are therefore longer.
Some organizations require that each motion brought to the governing body references a relevant portion of the mission statement. Such a rule raises the question of the means to weave this material into the organization’s tapestry, which is addressed in the next chapter. (Figure 3.1 dem- onstrates how mission, vision, and core values fit together.) Figure 3.1: Bringing together mission, vision, and core values Health care organizations must be intentional when creating their vision, values, and mission statements. At some level there have to be interlocking pieces that uphold the integrity of the organization.
Source: Courtesy of UC Irvine Health, 2013. 57 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct Codes of Ethics or Conduct Codifying the behavior of individuals within a community has ancient roots. The oldest discovered physical evidence of a code of conduct was a rock fragment containing the Code of Hammurabi, the edict of King Hammurabi of Babylonia dating back to around 1772 BCE.
While an institutional code of conduct or ethics should ideally be prescriptive in its language and precise enough to be followed, it may also be aspirational and paint a picture of a representa- tive member of the organizational community who lives by the core values of the institution and embodies the moral identity the institution is trying to achieve. For example, Trinity Health (2013) developed a code of guiding behaviors that encourages the following six characteristics:
We support each other in serving our patients and communities . • Convey compassion and care in serving external and internal customers/constituents. • Build collaborative relationships throughout the organization in order to share knowl - edge, skills, and resources. • Focus on finding solutions rather than blaming and complaining. • Make decisions in the interest of the UEM [Unified Enterprise Ministry]. • Support decisions, once they are made, both publicly and priv ately.
We communicate openly, honestly, respectfully and directly.
• Listen to and communicate respectfully with others. • Articulate ideas and solutions, clearly and succinctly. • Talk promptly and directly to an individual when there is a concern or problem. • Build trust through open, tw o-way communication.
We are fully present.
• Set aside distractions to center self and assure full attention to each patient, family, and team member. • Listen to people to understand the words and their meaning. • Openly appreciat e the gifts and contributions of others.
We are all accountable .
• Align personal actions, measurable performance, and responsibilities to UEM Mission and Goals. • Accept responsibility for actions, decisions and results. • Be accountable for the success of the larger organization. • Admit mistak es and limitations while demonstrating a “can-do” spirit to achieve re - sults. • Contribute at a high performance level to a positive, motivating environment. We trust and assume goodness in intentions .
• Encourage openness and sharing. • Seek first to understand, then to be understood. • Ask others with differ ent experiences for their point-of-view.
• Demonstrate genuine curiosity without judging. • Be inclusive—reach out and embr ace all people while living our Mission. 58 CHAPTER 3 Section 3.2 Values, Vision, and Mission Statements and Codes of Conduct We are continuous learners.
• Embrace change and prudent risk to find new ways to support the Mission. • Encourage new ideas to serve our patients and communities. • Provide and accept coaching and feedback. • Forgive past problems and use conflict as an opportunity for growth. • Develop oneself through a personal learning and development plan. Reprinted by permission of Trinity Health, Livonia, Michigan. Note that values, vision, and mission statements deal with what is important to us and what we do, whereas codes of conduct deal with how we will interact with each other. For example, Trinity Health’s statement requires open communication and personal accountability. A code of conduct is an opportunity for an organization to define its perception of successful human interaction. Fig- ure 3.2 outlines steps that an organization can take to help develop a successful code of conduct.
Figure 3.2: Steps to developing a code of conduct Employee behaviors often cause headaches for leaders of health care organizations. However, with a little planning, addressing inappropriate behaviors can be handled with a solid code of conduct.
Maimonides Medical Center’s (2009) Code of Mutual Respect is very different in tone and detail from Trinity Health’s code, yet it instills the same type of aspirational goal setting and makes clear the moral expectations of the organization’s community members. 59 CHAPTER 3 Section 3.3 Institutional Structures That Foster and Support Moral Identity 3.3 Institutional Structures That Foster and Support Moral Identity I n shaping its moral identity through the statements discussed above, a health care organization must also organize internal structures to address medical and administrative ethical issues and concerns. In addition to establishing a code of ethics and conduct, officials such as compliance officers, risk management officers, and offices of general counsel provide a broad range of over - sight. Working alongside these officials are institutional committees such as ethics committees and review boards. We will begin by examining some smaller structures, followed by ethics and research review committees. Web Field Trip: Moral Identity Statements Moral Identity Statements Exercise Instructions 1. Locate one example of a health care organization’s outward articulation of its moral identity.
This can be something like an advertisement, a credo, or the values, vision, and mission statements that larger health care organizations post on their websites. 2. Write a short critical paper (less than 1 page) in which you critically analyze this manifesta- tion of the organization’s moral identity. Evaluate the tone, images (if any), wording, and explicit and implicit values. Which parts of the organization’s identity that you may be famil - iar with are downplayed or unmentioned? Who is featured prominently? Sick patients? The healthy public? Care professionals? Administrators? Indigents waiting in the emergency department? Assess the outward expression of this institution’s moral identity using the fol - lowing criteria:
a. Effectiveness : Does the expression achieve what you think the institution is trying to convey? Evaluate how successful it is at connecting with the reader and conveying the message. b. Clarity : Does it express clear ideas and values? How? Does it, for example, give clear instances or examples of its professed commitments or values? Does the statement convey potentially conflicting values and interests? If so, does it indicate which values will prevail or how conflicts will be resolved? c. Honesty: Do you get the feeling that the expression is honest and forthcoming, or does it feel disingenuous or distract the reader from some unsightly facet of the organiza- tion’s identity? Does it accurately reflect what the institution’s primary values are, or does it deemphasize or ignore what you know is a prevailing value in that organization?
Give supporting evidence (while observing patient confidentiality and privileged infor - mation or communications). As indicated by the BEST project, statements alone are insufficient. Attention must be directed toward their creation and implementation. That forms the subject of the next section. 60 CHAPTER 3 Section 3.3 Institutional Structures That Foster and Support Moral Identity Other Structures To support its code of respect, Maimonides Medical Center has established a Respect Hotline telephone line, along with an e-mail account where behavior that is inconsistent with its Code of Mutual Respect can be reported. Maimonides has other institutional structures to help organize responses to ethical lapses as well as help foster and protect the organization’s moral identity. For example, there is a Medical Staff Subcommittee on Respect, which monitors physician compliance with the code (Maimonides, 2009). Committees such as this are a common way of handling day- to-day ethical issues that may arise within an institution. Web Field Trip: Maimonides Medical Center Code of Mutual Respect Web Field Trip In this web field trip, you will listen to a 2008 episode of The Brian Lehrer Show, a radio program on WNYC, in which Brian Lehrer interviews Dr. David L. Feldman, vice president of perioperative services at Maimonides Medical Center in Brooklyn, New York. Feldman talks about how the Joint Commis - sion, which accredits and certifies health care organizations in the United States, has begun to crack down on rude behavior by health care professionals and how health care organizations are combating this problem. Feldman talks about how Maimonides has instituted its Code of Mutual Respect that all staff and employees must abide by. It is firmly grounded in the core principles of the institution and, together with its detailed Corporate Compliance Code of Conduct, helps foster an ethical work environment conducive to quality health care while not settling for the minimal standards that “com- pliance” alone may connote.
Instructions 1. Listen to “Paging Dr. Jekyll” (ht tp://ww w.wn yc.o rg/shows/bl/2008/jul/29/paging-drjekyll/), a 2008 episode of The Brian Lehrer Show. 2. Read Maimonides Medical Center’s (2009) complete Code of Mutual Respect (ht tp://ww w .maim onidesmed.or g/Resource.ashx?sn=codeofm utualrespectrev709). 3. Write a short critical paper (less than one page) in which you critique the Code of Mutual Respect. Assess whether there are any potential gaps or missing elements that might be helpful to include in future versions, and try to identify any ethical problems that the code might not be well suited to handle. If appropriate, come up with some policy recommenda- tions for revisions to the code that will cover the issues you have spotted. 61 CHAPTER 3 Section 3.3 Institutional Structures That Foster and Support Moral Identity Institutional Ethics Committees In 1976 the New Jersey Supreme Court decision regarding Karen Ann Quinlan paved the way for the establishment of institutional ethics committees in hospitals around the country. Soon after returning home from a party, the 21-year-old Quinlan experienced two 15-minute periods of respi- ratory arrest. She was rushed to a hospital, where she lapsed into a persistent vegetative state.
Her father, Joseph Quinlan, approached the court with a request to be appointed Karen’s guardian so that he might consent to remove her from life support. Karen’s physicians, the local prosecutor, and the state attorney general opposed the request. Until the Quinlan case, the nation’s appel - late courts had not decided a termination of life support issue. Therefore, this was a case of first impression for the New Jersey Supreme Court. Quoting from the Baylor Law Review, the court in its opinion stated:
I suggest that it would be more appropriate to provide a regular forum for more input and dialogue in individual situations and to allow the responsibility of these judgments to be shared. Many hospitals have established an Ethics Committee composed of physicians, social workers, attorneys, and theologians, which serves to review the individual circumstances of ethical dilemma and which has provided much in the way of assistance and safeguards for patients and their medical care - takers. Generally, the authority of these committees is primarily restricted to the hospital setting and their official status is more that of an advisory body than of an enforcing body. [27 Baylor L. Rev. 6, 8–9 (1975)] ( In re Quinlan, 1976) Today ethics committees, also called bioethics committees, act in an advisory capacity to help determine whether to continue life support for patients with dire prognoses. Ethics committees were rarely found in hospitals in 1976, when Karen Ann Quinlan collapsed. Largely due to the rec- ommendation in In re Quinlan and subsequent endorsement by other state appellate courts that hospitals establish institutional ethics committees, today most health services organizations— from nursing homes to the largest academic medical centers—have some version of an institu - tional ethics committee.
In 1992 the Joint Commission, an independent, non-profit organization, provided accreditation and certification to more than 20,000 health care organizations in the United States. The Joint Commission required that hospitals institute a mechanism to resolve ethical issues such as that of Karen Ann Quinlan and others that had proved so vexing and contentious in the 1970s and 1980s. Today this requirement is usually met by having some variation of an institutional ethics committee . These committees are designed to deal proactively, as well as reactively, to ethical issues that the organization faces. Joint Commission standards and the reaccreditation process constitute a form of oversight of such committees. In many facilities the bioethics committee is under the responsibility of the medical staff.
There are a variety of institutional ethics committees used today. Some focus on clinical ethics issues (including offering clinical ethics consultation), while others look at research ethics (see discussion of institutional review boards later in this chapter), and still others confront administra- tive ethical or legal issues. There are also specialized committees (or subcommittees) that look at a subset of the issues mentioned above as well. Some institutions have multiple ethics committees, while others have a single general-purpose one, and still other health care organizations may have none. When a particular health care ethics committee is required by accreditation standards or law, its membership composition is usually prescribed by minimum standards in order to foster diversity of views and avoid conflicts of interest. 62 CHAPTER 3 Section 3.3 Institutional Structures That Foster and Support Moral Identity Activities and Functions As a best practice, the form of any organizational structure should follow its function. Therefore, the form of an ethics committee should flow from its function. Functions can take a number of forms (e.g., consultation, policy development, education), and the subject matter can vary (e.g., clinical, administrative, or research). This section will discuss these variables. Large and complex health services organizations such as acute-care hospitals and academic health centers would probably benefit from having ethics committees with expertise in clinical ethics and a separate committee or committees that deal with administrative ethical issues. This kind of specializa- tion and division of labor is desirable.
The ethical issues involved in clinical care—for example, whether life support should be removed from a patient or whether a patient who is unable to con- sent should have a particular surgery— often depend on an understanding of disease processes and physiology. The issues also generally involve the patient, the patient’s family, and the nursing and physician staff. These issues are quite dif - ferent than those in health care adminis - tration, which take the form of whether to purchase certain equipment or end a certain program. The participants are usually administrative and management personnel and can include the gover - nance of and representatives from the public. Unfortunately, it is still relatively rare to see an administrative ethics com- mittee that is specifically devoted to meeting regularly and discussing admin - istrative ethical issues (Darr, 2011).
Clinical ethics committees may be involved in policy development, ethics case review and consul - tation, and advisory opinions upon request. Their policy development role can range from review - ing or developing the informed consent forms and policies of the institution, to making large- scale resource allocation policies for emergencies or natural disasters. As we will see in Chapter 6, institutional ethics committees have also been called on to provide oversight (along with the institution’s risk-reduction mechanisms) of cases of medical mistakes and establish and maintain a culture of patient safety in an organization (Meaney, 2004).
A growing concern is for both clinical ethics consultation and institutional ethics committees to reflect the diversity of modern health care contexts as well as the competence and sensitivity to effectively and respectfully deal with cross-cultural clinical affairs. Professional organizations such as the American Society for Bioethics and Humanities have recently begun working on certifica- tion and/or accreditation standards for clinical ethical consultants, and so the role of institutional ethics committees in clinical ethics consultation may yet again be changing in the near future (Tarzian & ASBH Core Competencies Update Task Force, 2013). Associated Press/Andrew Shurtleff At the University of Virginia Medical Center, neurologist Madaline Harrison chairs a committee of physicians and other hospital employees that formally reviews ethics policies and develops regulations that will address a range of issues. Institutional ethics committees can be invaluable in resolving ethical issues that arise in a health care organization. 63 CHAPTER 3 Section 3.3 Institutional Structures That Foster and Support Moral Identity Institutional ethics committees are now largely seen as necessary and essential components of ethical health services organizations. Both clinical and administrative ethical issues are often bet- ter dealt with through committee approaches, rather than through unilateral decisions made by executives or directors. However, committees should be evaluated from time to time to assure that groupthink or institutional allegiances are not biasing the committee’s ethics decisions and that the institution is continually helping foster an ethical environment that helps the organization better achieve its stated goals.
Institutional Review Boards On the heels of the Nazi medical “research” atrocities of World War II, the Nuremberg Code (1947), along with the later Declaration of Helsinki (World Medical Association, 1964, revised 1975 & 1983), became the basis for the U.S. federal regulations (Public Welfare Protection of Human Subjects, 2004) that govern most medical research in the United States. These regula - tions also require independent committees to review and approve research protocols. In 1978 the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1978) issued The Belmont Report: Ethical Principles and Guidelines for the Protection of Human Subjects of Research , which identified the three basic principles: 1. respect for persons 2. beneficence/nonmaleficence 3. justice The Belmont Report , as well as the regulations we now follow in clinical research in the United States, differentiate between clinical practice that benefits the patient and nontherapeutic research (research where the subject is not expected to benefit directly from the trial). In the latter, the commission found the need for the consideration of certain applications: informed con - sent, assessment of risks and benefits, and selection of subjects. These further requirements, which include the voluntariness of the subjects and the requirement of informed consent, also suggest the Kantian principles of respect for persons as well as the principles of nonmaleficence and the virtues of justice and honesty. All are to be found as integral parts of our regulatory frame- works (Public Welfare Protection of Human Subjects, 2004; FDA, 2013).
The Belmont Report and subsequent regulations set the legal standard for the protection of sub - jects involved in clinical research in the United States. To implement the regulations and oversee research, the regulations established an organizational structure called the institutional review board (IRB). As a result, to conform to the regulations and to protect human subjects in clinical research, health care organizations conducting research with any level of federal funding must establish an IRB. IRBs must follow processes and guidelines set forth by the U.S. Department of Health and Human Services as well as the U.S. Food and Drug Administration (for trials that are likely to produce products or drugs meant for public sale). The processes and guidelines embody the principles set forth in The Belmont Report, such as informed consent documentation and peri- odic compliance review. IRBs are independent committees with diverse memberships that autho - rize and review most research that falls within the government’s definition of research involving human subjects (Public Welfare Protection of Human Subjects, 2004; FDA Protection of Human Subjects, 2004). IRBs must contain both scientific and nonscientific members and at least one rep- resentative from the community (Public Welfare Protection of Human Subjects, 2004). Although the direct effect of the regulations is limited to government-funded research, the indirect effect is that such research is so pervasive that the regulations establish the standard of practice for civil torts. 64 CHAPTER 3 Section 3.4 Chapter Highlights As a result, if a drug company, a medical device manufacturer, or even a college professor seeks to perform research that involves human subjects, the research and particularly the protection of the human subjects must be approved and overseen by an IRB when the research is federally funded or when researchers plan to seek FDA approval. Although found in other organizations, IRBs are part of many educational organizations and health care facilities. An IRB’s mandate is to ensure ethical clinical research and minimize risks to subjects. This is done by determining whether the risks to potential subjects are reasonable relative to any anticipated benefits to subjects or society.
IRBs must also make sure that informed consent is obtained from subjects or their legally autho- rized proxies, as well as monitor the trial’s safety, equity, and confidentiality. Additional safeguards are necessary when the proposed subjects are likely to be especially vulnerable to coercion or undue influence; in fact, the bulk of the regulations concerning IRBs are focused on the require- ments for informed consent, a concept that will be covered (in its clinical version) in Chapter 4.
Note that recently the government has extended the IRB’s authority to review and avoid conflicts of interest between the financial support of research and the investigator.
3.4 Chapter Highlights • The narrativ e of a health care organization’s identity should both reflect and prescribe the organization’s core principles and values. This is commonly done through three inter - related yet distinct foundational documents:
1. Values statements are those documents that attempt to identify the goods, prin - ciples, and commitments that the organization hopes and plans to be based on and to embody. 2. Vision statements are the inspirational and aspirational statements that define where the organization is headed in terms of actions and identity. 3. Mission statements are the documents that attempt to operationalize the goals set forth in the vision statements and that should reflect the underlying values articu- lated in the values statement of the organization. • We saw the importance of being thoughtful and purposeful when crafting these state- ments, as well as being sensitive to the evolving need to shape and reflect the organiza- tion’s moral identity. This includes being proactive in defusing potential ethical dilemmas as well as being wary of adopting an attitude of mere compliance with minimal stan- dards of conduct. • Lastly, we looked at the institutional structures that foster and support the moral identity of our organizations. We saw the various forms and frameworks that can help organizations achieve these purposes, including institutional codes of conduct, as well as the now nearly universal institutional ethics committees and review boards that resolve ethical disputes, ensure compliance, consult with clinicians, and form ethical policies in health services organizations. 65 CHAPTER 3 Section 3.4 Chapter Highlights Critical Thinking and Discussion Questions 1. Which three documents are traditionally part of an organization’s moral identity? 2. Compare and contrast values statements and vision statements. 3. Explain why some commonly stated values like innovation can be ethically troublesome. 4. Why should an organization’s mission statement provide specificity and action guidance? Case Study: Preventative Ethics Instructions: Identify the potential ethical dilemma in each of these scenarios below. Think about ways in which a change in policy or behavior by staff or employees of the health care organization could either avoid the potential ethics issue, or prevent similar dilemmas from occurring in the future.
Scenario A: After taking stock of your hospital’s inventory, you calculate that the number of working mechanical ventilators, while sufficient for the regular daily requirements of a hospital such as yours, are dangerously below the number suggested to keep on hand in case of emergencies such as an influ - enza epidemic. While some of the costs involved in stockpiling this kind of equipment are defrayed by the federal and state governments, purchasing the additional ventilators would still mean a sizable investment by your organization. You did not plan for this in this year’s budget, which has already been approved by the board of directors. If you choose to purchase the ventilators in the unlikely event that they will be needed this year, you will have to seek special permission from the board to amend the budget. The board, to be sure, will not be pleased by this seeming oversight, and you dread thought of having to do this at this time. 1. What is/are the potential ethical dilemma(s)? 2. What is/are your proposed solution(s), and why?
Scenario B : You notice that more of your skilled nursing facility’s senior citizens are now arriving at your facility with advanced directives that state their treatment preferences at the end-of-life. While you welcome this new development, you also notice that many of the advance directives contain boilerplate language that states “no heroic measures should be used when there is no longer hope for a meaningful recovery.” Much of the care that your patients receive at the end-of-life involves all sorts of medical procedures and interventions that would have been seen as “heroic” not so long ago.
In addition, none of the advance directives you’ve seen recently have specified what sorts of medical treatments and what circumstances the patient thinks are “heroic” and which are not. 1. What is/are the potential ethical dilemma(s)? 2. What is/are your proposed solution(s), and why?
Scenario C: You have always been proud of the fact that your clinic’s staff and employees rarely com - plain to you or your management team of ethics or compliance violations or concerns. However, after reading a journal article on the general reluctance of staff and employees to report ethical concerns or even grave problems to supervisors, you begin to wonder if your clinic’s “clean record” is true. The research article suggested that absent clear policies for non-retaliation toward whistleblowers, many ethical problems remain unreported. You wonder how difficult it will be to justify initiating any new pol - icies if there is no evidence that the policies are needed to address any specific problems at your clinic. 1. What is/are the potential ethical dilemma(s)? 2. What is/are your proposed solution(s), and why? 66 CHAPTER 3 Section 3.4 Chapter Highlights 5. Give one example of a specific policy or action that leadership can undertake to ensure that values, vision, and mission statements are integrated into the everyday operations of the organization. 6. Which of the following was NOT one of the criteria the researchers in the BEST project identified as a central ethical obligation for exemplary health care organizations?
a. Hold deeply a set of values emphasizing c are of the sick and the promotion of health. b. State clearly and forcefully those values it commits itself to and guides itself by. c. Prioritize profits to shareholders above all other values. d. Ensure that it acts on its values: It “walks the walk” as well as “talks the talk.” 7. Explain what “preventive ethics” means in health care administration and provide an example. 8. Why is “mere compliance” not enough for the ethical health manager and the ethical health care organization? 9. Name and explain one strategy to avoid the danger of settling for mere compliance with minimal standards. 10. What are some of the dangers of using patients’ stories to help convey your organiza- tion’s moral identity to members of the organization as well as the public at large? 11. What institutional structure oversees human subjects research that is at least partially federally funded? Key Terms code of conduct A compilation of a commu- nity’s or society’s rules for conduct. Although the values that codes are aiming to protect, endorse, or foster are often implied in the lan - guage used, codes generally focus on specific behaviors and actions that are forbidden or state the minimal behavior necessary to avoid incurring a punishment. institutional ethics committee Also called a bioethics committee, a group whose task is to deal proactively and reactively with ethical issues that the organization faces. There are many different institutional ethics committees used today. Some focus on clinical ethics issues (including offering clinical ethics consulta- tion) while others look at research ethics. Still others confront administrative ethical or legal issues. mission statement The statement that attempts to operationalize the goals set forth in the vision statement. It should reflect the underlying values articulated in the values statement of the organization. values statement A document in which a health care organization attempts to identify the goals, principles, and commitments that it plans to be based on; it contains the starting points from which the organization builds its moral identity as well as its practical proce- dures and processes. vision statement An inspirational and aspi - rational statement that defines where the organization is headed in terms of both actions and identity.
