1. Organizational Ethics In Health Care An Overview Philip Boyle, Ph.D. Vice President, Mission & Ethics www.CHE.ORG/ETHICS

2. What is organizational ethics? What is unique to OE? The nature of organizations—their ecology How to study organizations? What is unique about organizations? healthcare organizations? RC organizations?

3. Definitions Applied ethics family resemblances Business ethics Management ethics Corporate Ethics Institutional Ethics Organizational Ethics

4. Definitions Nash: “The study of how personal moral norms apply to the activities and goals of a commercial enterprise. It is not a separate moral standard, but the study of how the business context poses its own unique problems for the morals person who acts as agent of the system.” Boyle, et al. Focus on the choices of all individuals in an organization and on the choices of the organization as organization in bring fulfillment to individuals and the community

5. Definition OE evaluates of moral choices of individuals and the organization itself in pursuit of the organization’s mission. OE focuses on organizations as moral agents. OE also examines decision-makers inside and outside the organization

6. Moral agency of institutions Are we drinking the cool aid? In what ways are organizations moral actors?

7. Moral agency of institutions Philosophers—it is not a moral agent Theologians—it is a moral agent Mediators—it acts as IF it were a moral agent; helpful analogy

8. Moral Agency of Organizations Legal –19 th century property –1978 Pinto criminal behavior –1978 Corporation have free speech rights –1991 Sentencing guidelines –2010 Citizens Untied v. Fed Elction Commission

9. Moral Agency of Organizations Sociology—plain language –Organizations exist after an individual dies –Said to hire and fire –Said to pursue missions that override the mission of any individual –Its actions are not reducible to actions of employees

10. Moral Agency of Organizations Moral Held accountable Praised and Blamed Decision making—not on impulse Acts in rational ways--policies Creates culture

11. Case of Len 35-yr-old level 3 sex offender Drunk & raped minor at age 19 Enters St. Dymphna Clinic after + drug screen Alerts local division of justice per Megan’s law Police alert schools and they inform families Discuss –What’s the issue? –Who is responsible?

12. Moral Ecology Cell Individuals Groups Regional Ecosystems Ecosystem Biosphere Individual acts Moral agents Departments Institutions Organizations Healthcare system

13. Moral Ecology Advantages Honesty--clear about perspective Which level is more important? Disadvantages Other levels obscured Can obscure differences between organizations

14. The Actors & Risks Sponsors—clear role Boards--clear process Managers –Senior management—discretion –Middle Finance—conflicts of interest HR—hiring firing, promotion Marketing—truth in advertising Development—nature of gift acceptance Environmental services—safety IS--confidentilaity

15. The Actors & Risks Employees—common risks of agent- principle relationships Consumers/patients—participation & appeal Purchasers/vendors—nature of cooperation

16. Range of issues Across all organizations –Discretion and control –Resource allocation –Conflicts of interest Organization specific –Home health v. acute Department specific –Finance v. development

17. How to study organizations? Rational systems –Formal—examines policies Natural systems –Informal—examines real practices Open systems –External systems—examines liability, laws, regulations, etc.

18. How to study Formal Personnel arranged in a hierarchy of authority Those in policy making higher positions are regarded as professional managers Most relations can be described as principle- agent relationships Division of labor with each position having limited authorized actions Following policies and procedures Products are joint outputs

19. How to study Formal Risks Joint output--mission substitution Hierarchy --expert imperialism Clear roles--dithering, stalling, obstruction Managerial expertise--incompetence

20. How to study Informal Culture is the glue of the organization Values and beliefs of all participants and includes the internal and external interpretation of those beliefs Informal unstated ways of acting Difference between policy and actual practice Moral psychology –Wendy Carlton: In our Professional Opinion: –Charles Bosk: Forgive and Remember –Danial Kahneman and Amos Tversky Judgment under Uncertainty: Heuristics and Biases; –Michael Davis: “The Challenger Disaster” –Jerome Groopman: How Doctors Think

21. Uniqueness of health care organizations What distinguishes healthcare from others kinds of organizations? Opportunistic – rapidly changing Any organizations that participates in healthcare: Purchaser/Vendor/Provider Industrialization process: use of industrial techniques for predictable outcomes Move from a medical professional to managerial professional

22. Uniqueness of organizations What is unique about RC organizations? –What is unique about RC education? –What is unique about RC health care? God is Love #31-33

23. Mechanisms to address OE Values based discernment process Subcommittee of ethics committee Ad hoc groups Senior management team Mission Effectiveness Committees

24. Conclusions Moral agency of organizations How to study –Formal—policies –Informal—practice Overlap between clinical and organizational ethics Dig in with low hanging fruit Different mechanisms