It has been a trying year for the five nursing homes in the extended-care division of Engulf Health Care. Engulf has brought in a management team to restructure, lay off last-hired employees, and set up new policies and procedures.
Steve, a member of the management team, approaches Bob, the division's chaplain, and reports that a number of positions will be eliminated. The division CEO, a hard-driving businesswoman, has assigned responsibility for the downsizing to Steve, who fears news about layoffs will harm employee morale and lower residents'quality of care. Trust between employees and the organization is already shaky. After criticizing management for greed and insensitivity, Steve tells Bob their conversation is confidential.
This is a bad situation that could get worse. Upset, Bob wants to tell the division CEO that staff morale is suffering and employees should be told about the upcoming layoffs. Moreover, Bob wants to address the residents' anxieties. As chair of the extended care division's ethics committee, Bob considers bringing the matter up in that forum but is afraid of violating confidentiality.
Health care has always been a business, involving at a fundamental level the exchange of money for goods and services. The era of managed care has brought about a wave of mergers and restructurings and heightened the concern over conflicts between patients' welfare and the business side of health care.
Maintaining staff morale — and quality patient care — amid change is a challenge for managers. The Engulf Health Care scenario raises several ethical concerns in the chaplain's relationship with the CEO, his colleague Steve, and his obligations to his fellow employees and to the residents. Trust and confidentiality, in this setting, compete against the company's financial health, the employees' well-being, and the residents' quality of care.
The chaplain, Bob, is troubled by the staff's anxieties and their distrust of the organization's leadership. He is worried that employees will feel betrayal, anger, and resentment when the news breaks. He does not like how Engulf is handling the business.
It is easy to understand Bob's distrust and his own instinct for self-preservation. At cost-cutting time, pastoral care programs are not immune. At the same time, Bob takes his responsibility as a pastoral care provider seriously. His religious tradition values the pastor's prophetic role. Perhaps Steve saw him as an advocate who could speak for those less powerful. As chaplain, what are Bob's responsibilities to the organization, its employees, and the people whom they serve?
A competing claim is Bob's need to respect his co-worker's confidence. According to philosopher Sissela Bok in her 1982 book, Secrets, the pledge of secrecy alters our freedom of action. We promise to perform some action that will guard the secret — to keep silent at least, and perhaps to do more. While his co-worker's comments were not made in the context of the confessional, Bob nonetheless feels an obligation to sustain his promise to him. But, by faithfulness to the one, does he sacrifice the good of the many?
In nursing literature, Bob's dilemma is known as "moral distress," namely the powerlessness felt by those forced to adopt courses of action with which they are not entirely comfortable. If Bob approaches the CEO, he perhaps risks acting without full knowledge of the situation, and he would clearly violate the confidentiality of his talk with Steve. If he doesn't speak with the CEO, he is perhaps perpetuating a style of management-employee relations characterized by distrust and poor morale. Is there an option between violation of confidence and submission?
Bob considers approaching the CEO to comment only on his perceptions of morale. In this context, the CEO might even mention the layoffs. But would this strategy be duplicitous, fostering the very distrust and deception that Bob wants to dispel?
The attitudes of managers and clergy often seem diametrically opposed. In a 1988 study by Walter Benjamin of clergy/business executive relations, a pastor says: "Business has no moral vision. It is not interested in the common good. It wants only to maximize profit, destroy the power of labor, and dehumanize its workers." To this pastor, the dominant business virtue is greed. On the other hand, a CEO reported that "my clergyman doesn't understand the world of trade-offs. There is no 'free lunch.'" From the business side of the picture, when there is no (profit) margin, in time there will be no mission.
Business ethics and healthcare ethics are not necessarily incompatible. The question is how fiscal efficiency and responsibility (and profit) can be accomplished in a spirit that will make for the best outcome possible over time for the people concerned. Healthcare ethics in its broadest sense concerns the ways that healthcare workers treat patients, families, and one another. Employees have a right to accurate and timely information about developments that affect their jobs.
The chaplain, however, needs to appreciate management's responsibilities and accountabilities. Given the need to cut costs, if other remedies have been tried and layoffs are necessary, the CEO may have understandable concerns about employee morale, a concern that employees will look for other jobs, or that productivity will decline and patient care be affected.
Bob is reluctant to take the downsizing matter before the ethics committee, which serves primarily in an educational and advisory capacity. So what can he do? His best course is to work with Steve to design an ethically sensitive plan for the layoffs. If the organization is to be guided by its mission while recognizing the need to control costs, keeping a focus on the mission could direct the CEO to treat the employees with respect by acknowledging the tough times and enlisting their aid in finding ways to keep costs down. With a sound and sensitive plan in place — kept informed of developments and reasonably notified of upcoming cuts — employees could come to understand that the necessary downsizing will be handled as fairly as possible. A reasonable severance package and a solid outplacement program would demonstrate organizational concern. Informed of the need for cost-cutting measures, respected as members of the organization with some power to affect the course of events, employees might take a more positive approach. Combined with reassurance for residents and their families, these steps could produce the best outcome possible.
Quality patient care remains the goal. The evolution of healthcare ethics reflects the realization that achieving quality care means making ethics more than just another committee. It means that ethics in health care is fast becoming everybody's business.
