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Guiding Ethical Decision Making

In this lesson we will learn about developing organizational values, visions, and mission; and codes of ethics in health services.  An organization’s philosophy affects strategic management.  The philosophy must be articulated if objectives are to be consistent and set appropriately.  The organization’s view of its social responsibility should be reflected in its organizational philosophy and vision and mission statements.  Only then should strategic management occur.

Developing a Philosophy

The starting point for an organization to prevent and, if necessary, solve ethical problems is philosophy.  The statement of philosophy identifies values and principles reflecting the moral right and wrong for the organization, thus distinguishing the acceptable from unacceptable.  It is helpful if the philosophy statement is sufficiently precise that performance in achieving it can be measured.  At minimum, the statement of philosophy must be consistent with the law.

Culture of Pheromone. The values of an organization are reflected in its culture.  If they are positive, these values will bind the organization together.  The resulting congruence of values will enhance operational and mission effectiveness.  The organization’s value system is a metaphor for the queens’ pheromone. 

Content of a Philosophy Statement

Organizational Content.  The values and principles state in an organization’s philosophy establish a moral framework for its vision and mission. The philosophy provides a context and operative values – it gives delivery of health services a life, a meaning and recognizes that these values are unique and represent more than delivering a product or rendering a service.  Policies, procedures, and rules are derived from the mission statement and make the organization operational.  The approaches taken by health services organizations are varied.  Typically, those that are faith based have a greater focus on values and ethical principles.  The commitment to the values and ethical principles is not, however, exclusive to faith-based organizations.

Relationship with Patients.  One cannot imagine a health services organization that does not identify its role vis-à-vis patients in the context of respect for persons, beneficence, nonmalefience, and justice.  These value mandate delivery of medical services to patients with respect and in a manner that enhances human dignity.  Staff members must know their responsibilities and duties toward patients in this regard.  Patients are the reasons why the organization exists, and all efforts are directed at meeting patient needs by safely delivering high quality services.

Search and Test Procedure.  Search and Test Procedure is a process we can use to study ethical issues and come to some understanding of an answer to the dilemma. It includes a series of steps which define the problem, organize the reasoning, and ascertain the acceptability of our decision. The questions are laid out in a reasonable sequence. The overall objective is to develop an ethical position based on relevant questions and answers. In other words, if a potential solution to a problem survives the reasoning stages, we would be more confident that it is, truly, an adequate solution.

Relationships with Staff.  Like patients, employed and noemployed (typically physicians) staff are entitled to be treated with respect and loyalty.  Staff are the organization’s most important assets because, ultimately they determine the manner in which services are delivered.  Like patients, staff must not treated as means to an end. 

Relationship with the Community.  In some geographic areas, community (service area) and patients (or potential patients) are synonymous.  The organization’s philosophy should specify its relationship to the community:  What is its obligation to provide less than cost or free care to Medicaid patients or to those who cannot afford to pay? What is its obligation to provide controversial services such as abortion? Prospectively answering questions such as these causes the organization to consider important issues about itself and the role it can play. This probing assists in honing an organizational philosophy and provides an opportunity for introspection and staff involvement in establishing and strengthening a corporate culture.

Relationship with Other Institutions.  Revising the organizational philosophy is difficult but necessary as the external environment changes.  The organization must deal forthrightly and honestly with other entities, even actual or potential competitors.  This ethic fits with effective competition.  It simply means the organization competes honestly, with no hint of fraud or deception.

A variety of sources assists in developing

These questions begin the study of the subject. They assist us in seeking out possible solutions to the problem; Why are they adequate or not adequate? Are there justifications for using one or another? Maybe we can check out guidance from theories and/or codes of ethics to find an answer. Sometimes there is a logical answer in these places.
Remember: the idea is to get everything down on paper; kind of a brainstorming session with yourself (and a committee, if this is being done with a group.) The answers will begin to clear and filter with the more focused stages to come.
Test Stage 1: How Sound Is the Reasoning?
We need to find answers to the following questions:

1. What needs to be known?

2. Other information; technical data; personal information relating to the patient, facility, etc; detailed information relating to the patient that may alter our analysis of the problem.

3. Which evidence is relevant?

4. Is any of this data relevant to our decision? Does any have a bearing on our solution?

5. Are the likely consequences acceptable?

6. What are the long-range and short term consequences of the issue to be decided? Are there long-range and short-term consequences of any decision we have made at this time?

7. Are the most likely objections answerable?

8. Could we answer objections to our decisions at this time? Is there contrary information which we need to deal with at this time?

9. Does our solution stand the test of consistency?

10. Are our answers consistent with theory, data as gathered? Can you use this solution in all similar cases? Would we be proud to use this decision, to put our name on it? Are we avoiding some answers because we are not comfortable with them, or they don’t seem to fit?

Test Stage 2: Is Proper Respect for Human Beings Evident?
Look for answers to these questions:

1. Are rights respected and responsibilities observed? Are we thinking about all rights in this decision, including rights of the patient, family, medical care providers, etc.?

2. How would I like to be treated this way?

3. Would it be acceptable for everyone to do this or be treated this way? What if it is an unlikely option for the majority of people?

Test Stage 3: Is this Solution Realistic?
Answer these questions:

1. Are there adequate resources available? Is there enough support, funding, facilities, for your decision?

2. Does this solution expect too much of people? We cannot expect people to sacrifice if there is nothing in it for them.

Final Stage: Conclusion
Look back at your original findings. Have you changed your mind, based on your more complete understanding of the problem? Why or why not? How would you answer the dilemma? This should provide closure for this dilemma or issue.  This is just a sample of how to work through an ethical dilemma.  This process can be applied by you as an individual or in a group setting.

Problems of Consistency:
Different codes often give conflicting guidance for the same conduct. Many times, duties will conflict when applied in different situations. You may see such wording, as is seen in the International Code of Nursing Ethics:  “…to conserve life, to alleviate suffering, and to promote health.”
Sometimes it is not possible to accomplish all three with the same patient. Perhaps this is seen as an ideal to strive for. Maybe this inconsistency is illustrated better when looking at the AMA Code and the British Medical Association Code in discussing confidentiality.
The AMA Code states:
“The physician may not reveal the confidence entrusted to him in the course of medical attendance or any of the deficiencies he may observe in the character of his patients, unless required to do so by law or unless it becomes necessary to protect the welfare of the individual or of society.”
The British Medical Association Code states:
“If in the opinion of the doctor, disclosure of confidential information to a third party seems to be in the best interest of the patient, it is the doctor’s duty to make every effort to allow the information to be given to a third party, but where the patient refuses, the refusal must be respected.”
Which code should we use? If we are to use either — or neither — of these codes, we would have to look for an answer based on other criteria. There could be, according to either of these codes, a time when there really is no such thing as absolute confidentiality.

Problems of Questionable Morality:
A code may explicitly forbid a particular practice which is now deemed a viable choice, simply because it was written at a time when that practice was illegal. For example, the Hippocratic Oath forbids the practice of abortion, yet it is legal in this country to participate in an abortion. Some people believe that an absolute ban on abortion would violate the moral and legal right of women. In their minds, this part of the Hippocratic Oath is, in itself, immoral.
Looking deeper into the Hippocratic Oath, it also embodies a less-than acceptable concept of patient/physician relationships. It begins with a pledge of loyalty and devotion to other physicians. It allows a sort of secrecy to the group — an idea that one physician should not question the judgment of another. Although this is falling out of favor with the group, it is still difficult to get one physician to testify against or question another unless there is gross negligence.  Regarding relationships to patients, the Hippocratic Oath addresses itself only to what the doctor will do for the benefit of the patient:
“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients.”   The patient’s own conception of what is best is not mentioned. The physician is to protect us from ourselves whenever our values happen to conflict with his conception of our well-being (Paternalistic idea!).
Ethical codes undoubtedly serve the purpose of raising moral standards of practice, but we still must look elsewhere at times to answer some ethical and moral questions. We can use them as a guide, but rarely can use them as answers to our dilemmas.

Codes of Professional Ethics (Continued)

Since the time of Hippocrates, those in the health services profession have searched for “moral guidance” in codes specifying the duties of physicians. For example, the American Medical Association, World Medical Association, British Medical Association, all publish “codes of ethics” containing high standards of virtue in medical practice. The question is: Do these codes constitute a self-contained group of principles or must they be supplemented by others?
What problems do you see in the codes of ethics you have read or studied? Researchers have noted three general kinds of problems with codes of conduct:
            Problems of Application
            Problems of Consistency
            Problems of Morality
Problems of Application:
Because of their general nature, they must be vague and undefined. They cannot be applied in all situations and with all problems, so they remain only general or “ideal.”
The Hippocratic Oath says:
“Whatever, in connection with my professional practice, I see or hear…which ought not to be spoken of abroad, I will not divulge..should be kept secret.”  What should be divulged? We are not really told. A weakness with codes is that they often leave important terms unanalyzed or undefined, leaving us to guess at their application.
Problems of Consistency:
Different codes often give conflicting guidance for the same conduct. Many times, duties will conflict when applied in different situations. You may see such wording, as is seen in the International Code of Nursing Ethics:  “…to conserve life, to alleviate suffering, and to promote health”.  Sometimes it is not possible to accomplish all three with the same patient. Perhaps this is seen as an ideal to strive for. Maybe this inconsistency is illustrated better when looking at the AMA Code and the British Medical Association Code in discussing confidentiality.
The AMA Code states:
“The physician may not reveal the confidence entrusted to him in the course of medical attendance or any of the deficiencies he may observe in the character of his patients, unless required to do so by law or unless it becomes necessary to protect the welfare of the individual or of society.”
The British Medical Association Code states:
“If in the opinion of the doctor, disclosure of confidential information to a third party seems to be in the best interest of the patient, it is the doctor’s duty to make every effort to allow the information to be given to a third party, but where the patient refuses, the refusal must be respected.”
Which code should we use? If we are to use either — or neither — of these codes, we would have to look for an answer based on other criteria. There could be, according to either of these codes, a time when there really is no such thing as absolute confidentiality.
Problems of Questionable Morality
A code may explicitly forbid a particular practice which is now deemed a viable choice, simply because it was written at a time when that practice was illegal. For example, the Hippocratic Oath forbids the practice of abortion, yet it is legal in this country to participate in an abortion. Some people believe that an absolute ban on abortion would violate the moral and legal right of women. In their minds, this part of the Hippocratic Oath is, in itself, immoral.
Looking deeper into the Hippocratic Oath, it also embodies a less-than acceptable concept of patient/physician relationships. It begins with a pledge of loyalty and devotion to other physicians. It allows a sort of secrecy to the group — an idea that one physician should not question the judgment of another. Although this is falling out of favor with the group, it is still difficult to get one physician to testify against or question another unless there is gross negligence. Regarding relationships to patients, the Hippocratic Oath addresses itself only to what the doctor will do for the benefit of the patient:
“I will follow that system of regimen which, according to my ability and judgment, I consider for the benefit of my patients”.  The patient’s own conception of what is best is not mentioned. The physician is to protect us from ourselves whenever our values happen to conflict with his conception of our well-being (Paternalistic idea!).
Ethical codes undoubtedly serve the purpose of raising moral standards of practice, but we still must look elsewhere at times to answer some ethical and moral questions. We can use them as a guide, but rarely can use them as answers to our dilemmas.

Mission Statement Instructions

Statement of an organization that contains detailed information about the overall direction and purpose of the organization.  Keys To A Quality Mission Statement: 

· Is an administrative statement that guides planning and decision making

· Not restricted by any time element

· Should contain philosophy of organization

· Should specify level and type of services provided  

· Should set forth the major functions of the organization as identified by governing board

Note:  A mission statement is not a goal since a goal has a specific function, a different definition from that of a mission statement and of an objective.

Goals

Goals as they pertain to health and health promotion, social and health services planning is a statement of quantifiable desired future state or condition.

· Goals are accomplished by activities

· Tools used to describe the specific activities of the goals are called objectives.

· Are long-range

· Lack deadlines

· Relatively broad in scope

· Provides guidance for establishment of objectives

Objectives

· Objectives used for attainment of goals and fulfillment of the mission statement

· Objectives have deadlines—goals do not

· Objectives, as used in health promotion is any short-term, measurable, specific activity having a time limit or timeline for completion.

· Objectives used to reach goals.

· Specify who, to what extent, under what conditions, by what standards, and within what time period certain activities are to be perform.