Consider this clinical conflict: Ethel, an elderly, long-stay patient with multiple organ systems failure, cannot be moved to another unit because someone involved believes she does not fit the criteria for transfer; for example, "a patient must be transferred if moribund," or "no futile care will be given on this unit."
We have all experienced the inability to come to an agreeable solution in situations like this, especially inasmuch as the conversation relies on a traditional bioethics analysis commonly used in clinical situations and employed by ethics committees. Why?
If the disagreement were viewed through the lens of a traditional moral analysis, much of the discussion would be centered on self-determination and autonomy: Who decides on this request for more services? Is this a clinician's or a patient's decision? If the patient is incapacitated and unable to make this decision, who does? As stalemates go, situations like this one are often decided on the morally unsatisfying basis of who has the real or perceived power.
Traditional analysis might also counter this reasoning with appeals to justice arguments, or that stewardship demands clinicians not waste valuable, sometimes limited, resources. Frustratingly, discussion about these cases often ends up at an impasse. Moral analysis from the perspective of organizational ethics might help participants see the forest though the trees, offering fresh insight and attention to details of allocations cases that otherwise go unobserved and undiscussed.
Organizational ethics attends not only to the choices of individuals, but also to the choices of the organization. Organizational choices are most apparent in policies because everyone in the institution participates—managers propose policy, trustees approve it, and employees carry it out. Policies are the organization's choices inasmuch as the institution requires that the entire staff act in a manner consistent with policy. Allocation policies are the most pervasive policies because they are woven through the entire organization. The subjects they address range from admission and retention on units—as in the case of Ethel—to purchasing policies for drug formularies, to clinical practice guidelines, and to hiring and staffing patterns.
Beyond these formal policies, an organization has informal patterns of allocation that become de facto policy. These include choices that are part of an organization's culture, such as traditions of not following certain policies, or understandings about professional authority—physicians, for example, might have the final say about allocation decisions. This may also include staff biases, when patients or families, depending upon their personalities, are given more or fewer resources.
When a moral lens is focused on allocation policies and practices, formal or informal, the deep moral commitments of an organization come forward and a different set of practical questions are applied to the analysis. In the case of Ethel the questions would include: Who made the policy about transferring moribund patients? Is it a formal or informal policy? If it is a formal policy, has it been appropriately reviewed? Does everyone consistently follow the policy? Are the criteria in the policy—the definition of moribund or futile, for example—understood and agreed upon by everyone? If there is no agreement there may be inconsistent application of the policy to similarly situated patients. Have patients and/or families received notice of the policy so they can make other arrangements if they do not agree? Does the policy supply means for appeal if staff, patients, or families disagree? Is the policy in force throughout the institution, or is it used selectively on some units or with certain patients?
An organizational ethics perspective shifts the moral focus. Different questions are asked: Is it defensible to limit treatment to this patient? What criteria trigger the allocation of the resource? Are the criteria clear, agreed upon, and applied fairly? Who in the organization should make decisions to limit treatment? Who participated in developing the policy? Different facts must be gathered: Is the current policy always followed? Are there formal or informal exceptions? Do staff members have practices or routines that violate the policy? Who follows the policy? If it is not followed was it irrelevant, inconvenient, or simply ignored? Different moral alternatives are presented. Moral analysis is refocused and the issue shifts from an impasse about patient autonomy to a discussion about how policy is constructed: Who participated in constructing this policy? Are there adequate checks and balances? Has the policy been public for all to see? Are the terms of the policy clear and unequivocal?
Organizational ethics analysis does not overlook the choices of individuals within an organization. It is a perspective that examines the moral identity of the organization—its moral culture. Ethics committees wishing to embark on organizational ethics analysis will have to supplement familiar questions and fact gathering with a new way of mapping the moral terrain.
