Articles discussed: Paul Schyve, "Patient Rights and Organization Ethics: The Joint Commission Perspective," Bioethics Forum 12, no. 2 (Summer 1996): 13-20; Van Rensselaer Potter, "Individuals Bear Responsibility," Bioethics Forum 12, no. 2 (Summer 1996): 27-28.
Do organizations have "ethics"? The question may seem to invite a cynical response, but it should be asked in good faith. "Organizational ethics" is not only the ethical buzzword of the '90s, it has also begun to infuse healthcare organizations. The term covers a wide area: the conduct of business affairs; decision-making processes; actual and potential conflicts of interest; appropriate use and allocation of financial and technological resources; human resource questions; and the relation of the organization's actual activities to its stated mission and values.
Proponents of organizational ethics contend that an organization's ethical responsibilities differ in kind from the responsibilities of individuals who work for it or those (such as trustees or non-employed physicians) who are associated with it. Paul Schyve's article emphasizes the responsibility of the organization as a whole for its ethical behavior.
"ORGANIZATION ETHICS": THE JOINT COMMISSION
Schyve, an executive of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), sketches the development of JCAHO standards for "organization ethics." Schyve offers a helpful Cook's tour of the "expanding paradigm" of healthcare ethics. The paradigm's foundation is each practitioner's obligation to the patient, a focus that dominates healthcare ethics from the time of Hippocrates until today. Only recently has a second "source of obligation" arisen with the growing recognition that patients have "rights" in their relationships with healthcare providers. The dual recognition of professionals' obligations and patients' rights fostered a dawning awareness in Joint Commission statements and standards of the 1970s that organizations had "an obligation to respect patients' rights" (or, perhaps better, to act to support respect for patients' rights).
Schyve does not naively suppose that any structural "fix" will prove a panacea for organizations' ethical challenges. Every "mechanism" for healthcare delivery has its downside; for example, if 1990s managed care promotes "underutilization" of services, the older fee-for-service medicine sponsored "overutilization." On the other hand, simply locating organizational ethics in "the personal ethics of each practitioner and administrator" leaves too much to the vicissitudes of individual character. Organizations have no real choice: they must respond to new ethical challenges.
In line with this perception, the 1995 JCAHO hospital accreditation manual added "organization ethics" standards to existing standards on patient rights. These standards call for a "code" of "ethical behavior" in each accredited organization and identify several areas of activity that the code should address. However, while the code of behavior should "ensure" that an organization's business and patient care are conducted in "an honest, decent, and proper manner," the burden of specifying the meaning of those terms resides with the organization.
Schyve recognizes that mere compliance with organizational ethics standards does not exhaust the organization's responsibility to make itself "accountable." Organizations should go above and beyond the letter of the law by going public: disclosing ethical risks and their possible effects on patient-customers, identifying safeguards intended to minimize such risks, and actively encouraging patients and the public to raise questions about the at-risk areas. Thus, for example, an organization could publicize its "code of business ethics" and its criteria for admitting, transferring, and discharging patients. (It could even, says Schyve, "encourage patients to review their bills"!)
Schyve also outlines distinctive ethical challenges managed care organizations encounter as they respond to enormous cost-containment pressures with cost-control incentives to providers. Recent JCAHO standards have required accredited managed care organizations to "protect the integrity of clinical decision making" and make publicly available their policies on the relationship between incentives and the use of services. (New standards also require hospitals to "protect" clinical decision making against potential adverse effects of financial incentives.) Such standards are more specific than earlier ones in identifying the organizational good to be done and evil to be avoided, both administratively and clinically. In the process they make a critical affirmation: Preserving the integrity of clinical decision making is indispensable to quality patient care.
NO SUBSTITUTE FOR INDIVIDUAL VIRTUE
The Joint Commission emphasizes the development of organizational mechanisms to address ethical problems. Van Rensselaer Potter sounds a prophetic counterpoint by stressing that, even in so-called organizational ethics, "individuals bear the responsibility." Potter, an emeritus oncology professor, is convinced that bioethics must reach into organizations, including corporations and healthcare organizations. But he takes a dim view of any assignment of moral agency and responsibility to the organization itself. Organizational "systems" and "processes," he implies, are the product of human action, and individuals cannot take moral refuge by laying blame on non-personal systems and processes.
"Every organization . . . has goals and a 'way of doing things' that may appear to us as ethical or unethical." Nevertheless, Potter reminds us that the organization's goals and culture came from somewhere. An organization's leaders and key staff cannot avoid the burden of responsibility for the organization's actions and moral climate. They must be proactive by identifying potential ethical problems, addressing them before they arise and responding appropriately when "'the organization' acts unethically."
Potter believes the morally responsible individual can be lost— or can hide— in the current focus on the organization's ethics. Individuals must, instead, speak out of "conviction as to what is right and just" and display the virtues of courage, persistence, and a readiness to speak up "at whatever cost." No organizational fatalist, Potter displays a modest faith in the ability of organizations to change course — if courageous individuals take the necessary risks to initiate the process.
The JCAHO approach, as outlined by Schyve, stresses that "mechanisms" can assure or promote ethical behavior, and implicitly recognizes that an organization can indeed support or hinder individuals in doing good and avoiding evil. Yet the existence of such mechanisms can never eliminate individuals' responsibility to be forthright, persistent, and, yes, courageous in mobilizing an organizational response when ethical concerns arise.
WHAT'S FAITH GOT TO DO WITH IT?
Judaism and Christianity both have perspectives on the question of individual versus corporate agency in organizations. Each tradition recognizes that individuals, particularly those in leadership positions, are responsible for the moral direction of such collective bodies as the nation and the religious community, yet each tradition also holds such bodies collectively responsible for living out their faith and values.
But the question is not only about ethics but about power. Both traditions attest the experience of forces or "powers" in our common life that have a life of their own. Though humanly created, these realities seem suprahuman in their ability to influence individual and collective behavior. Today the all-consuming market economy and modern bureaucratic organizations — including healthcare organizations — might count as such "powers."
The traditions see an invisible, "spiritual" dimension in such realities — an unseen but real force that can, for good or ill, affect the spirituality of the individuals who encounter it. Hence it is not only what is explicit, visible, and formalized in organizations that challenges us. It is the spirit of the organization — its climate or "culture," the sum total of collective attitudes and assumptions, its ways of being and doing — which any attempt at organizational ethics must also consider and address.
