An anonymous caller phones Partnership Health Care's Business Conduct Hotline, upset that PHC's health plan no longer pays for assistant surgeons on some procedures. (Principal surgeons must pay out of pocket if they require assistance.) The caller believes the policy puts patients at risk and that financial disincentives cause a conflict of interest by rewarding surgeons for saving money. Should employers agree to protocols that might facilitate substandard care?

Substantive ethical concerns must be identified in this case and a determination made as to whether the caller's distress is justified.

First, it should be asked if the caller's concerns are more appropriate for the Business Conduct Committee or an organizational ethics body. Business conduct programs address institutional compliance with state and federal laws about fraud and abuse, improper billing, discrimination, and sexual harassment. If PHC owns the surgical practice, and the health plan incentives encourage substandard care that could result in liability, the business conduct administrator should be involved. In this case, however, the administrator believes there is no liability and that the concerns are more appropriate for the system's ethics officer.

The issues here are different from traditional clinical ethical questions. Conflicts of interest, patient safety, and standards of care have obvious ramifications for clinical care, but managed care (which emphasizes cost controls and efficient care delivery) heightens attention to organizational responsibility for creating systems that provide the framework for individual decisions.

The caller's concerns raise moral issues within the purview of organizational ethics. Is PHC contracting with a health plan that creates the conditions for substandard care? If PHC does not have an institutional body that can review organizational ethics issues, it should create one as an extension of its clinical ethics committee to determine whether the health plan's restriction of reimbursement for assistant surgeons is defensible. If outcomes data show that surgical assistance is unnecessary for some procedures and that patient safety is not compromised, then the plan is not immoral.

How can organizational ethics leaders learn of important issues? Leaders must educate employees about both business conduct and organizational ethics and encourage them to come forward with concerns. Prompt referral in this case indicates good cooperation between PHC's business conduct and organizational ethics bodies, but PHC associates should know how to access their organizational ethics program directly and understand its function. Names and telephone numbers of program members should be circulated and the program's activities regularly publicized.

What response should PHC associates expect?

The decisions an organizational ethics group makes may not always satisfy everyone, but prompt attention to inquiries is key to credibility. PHC should respond to questions in no more than one month. Responses might be published in a newsletter to preserve caller anonymity. Associates who agree to identify themselves could be invited to consultations. If there are recurring issues, associate feedback and in-service education should be provided.