Saturday, September 29, 2007

Say it ain’t so Bristol-Meyers Squibb

When I read about the $515 million fine Bristol-Meyers Squibb paid for illegal marketing of its antipsychotic drug Abilify I felt like the young Chicago White Sox fan in 1919 (the year of the “Black Sox” fix of the World Series) who said to his hero Joe Jackson – “say it ain’t so Joe!”

Unfortunately for the young fan, it was so.

I have several patients who have derived excellent benefit from Abilify. We have spoken about how grateful we are to have a medication that is serving them so well. The manufacturer of the product is – in an emotional sense – a member of the treatment team. For us the exposure of Bristol-Meyers Squibb’s illegal practices isn’t just a fact about “business.” It is a taint on the caretaking process, like news about psychiatrists exploiting their patients sexually.

All those involved in health care are in it together. Bristol-Meyers Squibb’s lapse of integrity doesn't just violate business rules and create potential harms through false advertising -- it contributes to reducing trust even for those who benefit from using its products.

Wednesday, September 26, 2007

The Roar on the Other Side of Silence

The September 27th issue of the New England Journal of Medicine features a short article by Dr. Katherine Treadway that lucidly describes the way medical students and residents learn to detach themselves from the human meaning of the life and death events they are involved with in becoming physicians. Treadway explains in a compassionate manner that if students did not distance themselves from the dead person (“cadaver”) they dissect in anatomy class they might faint rather than learn. Likewise with surgery and the effort to resuscitate people who have experienced cardiac arrest.

The novelist George Eliot described this phenomenon in an unforgettable manner: "If we had a keen vision of all that is ordinary in human life, it would be like hearing the grass grow or the squirrel's heart beat, and we should die of that roar which is the other side of silence. "

The same dynamic applies to health organizations. Insurance companies talk about “covered lives.” Policy analysts discuss “consumers” (i.e. – patients) and “providers” (i.e. – caretakers). These terms serve an important purpose -- they capture a component of reality that might be overlooked or underemphasized. But the detachment that allows efficient functioning can deprive those in organizations of a textured appreciation of what their work, whether in medical records, a billing office, building services or the executive suite, means to real living people. With too little detachment we are overcome by the roar on the other side of silence. But with too much detachment health work becomes sterile, and those we serve know our hearts are not in what we do.

A key function of organizational ethics is to help organizations get the balance right – not too little detachment but not too much. Organizations that aspire to excellence must risk listening to the dangerous roar.

Tuesday, September 25, 2007

The Moral Ethos of U.S. Health Care

An excellent article by Gregg Bloche in the September 20th issue of the New England Journal of Medicine examines the current moral ethos of U.S. health care in a broad historical context. Bloche suggests that a society’s readiness to provide expansive social insurance (such as health care for all) is a reciprocal of the demand that its citizens be prepared to sacrifice themselves in war. Now that war is the province of a small volunteer military there is less readiness to treat health care as a right and more demand for individual responsibility.

Bloche predicts that “if the United States is to come close to universal coverage, personal responsibility will need to play a larger role than it did in the mid-20th century welfare state…The new compact is likely to start with an enhanced sense of individual obligation – to eat sensibly, exercise regularly, avoid smoking, and otherwise care for ourselves. It may include an obligation to buy insurance.”

Bloche is describing this perspective – not defending it. His aim is to offer a guardedly optimistic view of how health care for all might actually be achieved within the political culture he believes we are in.

Sunday, September 23, 2007

Using Organizational Structures to Achieve Disgrace and Profit

A must-read New York Times article about the nursing home industry demonstrates how shrewd design of organizational structures can create unethical outcomes and, at the same time, mega profits.

Reporter Charles Duhigg describes in excruciating detail how the Warburg Pincus private equity firm purchased a Florida nursing home company in 2002, stripped the homes of trained staff, allowed care to deteriorate, and insulated itself from liability through dizzyingly complex layers of interlocking corporations.

Arnold Whitman, the only executive brave enough to talk with Duhigg explained the organizational structure this way: “Lawyers were suing nursing homes because they knew the companies were worth billions of dollars, so we made the companies smaller and poorer, and the lawsuits have diminished.”

Whitman invokes a “we-are-no-worse-than-anyone-else” argument to defend Warburg Pincus’s ethics: “We should be recognized for supporting this industry when almost everyone else was running away.” This claim would have moral force if the new owners at least tried to reengineer “production processes” at the homes to achieve better outcomes per dollar invested rather than simply slashing costs in a way that allowed them to resell the chain to General Electric four years after the original purchase at an estimated profit of $500 million.

In addition to blocking suits, the corporate layering insulates owners from existential recognition of the pain they are inflicting. Ethical health care requires empathy by all who are involved in it – not just front line workers. If the owners’ parents were residents of the nursing home chain it is not likely that staffing would have been so brutally cut.

If the New York Times had brought this kind of reportorial skill to bear on U.S. government claims prior to the invasion of Iraq we might now have some governmental energy to pay attention to the nursing home disgrace.

Friday, September 21, 2007

Searching for a Secular Health Care Ethic

Recent articles in the Boston Globe about the effort to create a “church for those who reject religion” and the New York Times asking “Is ‘Do Unto Others’ Written into our Genes?” have important implications for the ethics of health organizations.

All who share the conviction that health care is a calling have to ask – where does the call come from? In my posting on September 10th I discussed the Catholic view that health care is a sacred ministry. Participants in faith-based systems can anchor their sense of mission in the teachings of their faith. But where do secular organizations find their anchor?

The question is eminently practical. Given that one sixth of the economy goes to health care, health organizations rightly see themselves as businesses. But business can swamp calling. The practical challenge is integrating business ethics and health care ideals. Faith-based systems can address this tension through mission offices whose role it is to ensure continuous attention to mission in all aspects of the organization’s activities.

The Boston Globe article describes the humanist chaplaincy at Harvard University and the effort to create a non-theological community of shared ideals. This is the challenge leaders in health organizations must grapple with. The effort to create action oriented non-theological communities in the U.S. goes back at least to Felix Adler's founding of the Ethical Culture Society in 1876. The history of the humanist movement has valuable lessons for secular health care.

The New York Times article presents speculations by evolutionary psychologists that the Golden Rule has adaptive value for our species and may have a genetic basis. While first year philosophy students understand that "is does not imply ought," a sense of mission does not come from logic alone. Believing that care for others is "natural" and embedded in our biology and the history of our species can add emotional spark to a non-theological sense of mission.

I hope readers will share their personal and organizational observations about what nourishes effective, successful mission-driven health enterprises.

Saturday, September 15, 2007

Ethically Admirable Health Care Competition

We in the U.S. pride ourselves on religious diversity, but in truth we have a national religion – market economics. We worship markets with the fervor of fundamentalists. We treat ideas like “competition is the best way to drive improvement” as sacred truths, not hypotheses.

Unfortunately, health care competition often drives a race to the bottom. Hospitals jettison medically important but unprofitable “service lines.” Insurers cherry-pick enrollees. Medical students abandon primary care and flock to plastic surgery and other lucrative specialties.

Today’s New York Times has a story about Cincinnati Children’s Hospital Medical Center that shows the bright side of competition. Six years ago when Cincinnati Children’s concluded it needed a new strategy it decided to specialize in niche areas where novel approaches to care were needed. It has developed special expertise in treating Fanconi anemia, a serious but rare genetic disorder, and reports that it treats one third of the 300 Fanconi patients in the U.S. Similarly, it has developed a distinctive colorectal program which its website describes as “the first and only pediatric colorectal center in the world!”

Cincinnati Children’s strategy is paying off for the bottom line as well as for improved population health. The strategy marries medical ideals – caring for the sick in a high quality manner – with shrewd program choices. Health care is a calling, and this is the right kind of competition.

Competition is an important part of a national strategy for improving health care. But sustaining and nourishing the structures and values that make health care a calling is more important.

Thursday, September 13, 2007

Ethics and Elbow Grease

Organizational ethics isn’t just about hospitals, group practices and health plans.The larger system within which health care occurs can usefully be regarded as a form of organization structured – for better or worse – around values. Advancing key values requires elbow grease. And time.

The mental health peer support movement provides a superb example of the role of elbow grease in changing the ethos of the health system. For the past 10 -15 years mental health consumer activists have been advocating for a “recovery orientation” – approaching those with serious mental disorders in a spirit of optimism about their futures and a focus on what will contribute to a meaningful and satisfying life. They want a person-centric – not professional-centric – care and support system.

Peer support services offered by individuals who are themselves in recovery from mental health and substance abuse disorders is an important manifestation of the recovery orientation. Georgia was the first state to offer these services. Consumer advocate Larry Fricks labored in the trenches for years to create a training program for peers and get Georgia Medicaid to pay for peer services. South Carolina saw what Georgia did and was next. Other states followed.

Last month CMS put its imprimatur on peer services by issuing a “Dear State Medicaid Director” advisory about the rationale for peer services and the prerequisites for getting these services paid for. In Churchill’s terms the advisory isn’t the end of professional-centrism in the care system or even the beginning of the end, but it is certainly the end of the beginning. It has taken countless hours of hard work by consumer advocates and their allies to create the infrastructure and the evidence that allows this kind of change.

Good ethics and elbow grease make a potent combination!

Monday, September 10, 2007

A Jewish fan of Catholic Organizational Ethics

On a research visit in 1999 to the Columbus, Ohio branch of Holy Cross Health System, we were told by the sister who led the organization that many of the doctors at one of their facilities were Jewish. With a mischievous smile she added – “as long as we stay away from a few specific issues we get along wonderfully, because we share the belief that medicine is a calling.” Her comment resonated for me. Although I am Jewish I was electrified by Holy Cross’s deeply felt mission – “to witness Christ’s love through excellence in health care.” (My colleagues Steve Pearson, Ezekiel Emanuel and I have since described the visit in No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence. )

I understand my response to a program based on a theology I do not share better since reading the excellent special section on organizational ethics in the November/December 2006 issue of Health Progress, a publication of the Catholic Health Association.
The Association describes its health care activities as a “ministry…rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit.” I believe the people I have most admired over the years in health care share these values, even though many, including myself, derive different conclusions about reproductive ethics than the Catholic Church does from the view that “every life [is] a sacred gift.”

In the opening essay, John Gallagher puts organizations front and center for health care ethics: “While personal integrity and virtue remain matters of key importance, what is now of at least equal importance is the integrity and virtue of the institution, the institutional structures through which health care is mediated.” David Ozar takes issue with the “Myth of Enough Good People,” which he defines as the belief that “if only there were enough good people making decisions in the organization…then everything that happened in the organization and everything it did would be good as well…” Ozar argues cogently that organizations should be viewed as “single, unitary actors” and held accountable for the ethics of their conduct as organizations the way we hold individuals ethically accountable for their conduct as individuals.

If we see health care as a sacred ministry and health organizations as moral agents, everything health organizations do comes under a spotlight. This is all to the good. Everyone’s work in health care is ennobled by recognizing its deep human importance, and high ethical expectations for everything we do encourage us to do all that can be done.

Not surprisingly, Catholic health institutions have been in the vanguard of developing organizational ethics programs, and the Catholic Health Association is probably the group with the most extensive experience of grappling with organizational ethics issues. Sister Patricia Talone offers practical advice on how to start an organizational ethics committee. And, in another issue of Health Progress, Brian O’Toole presents a useful description of committee function in the Sisters of Mercy Health System.

Everyone concerned with health care organizational ethics – of whatever religious outlook or lack thereof – can learn from the experience of Catholic health programs!

Monday, September 3, 2007

Harvard Pilgrim Health Care’s Approach to Organizational Ethics

Since 1996 Harvard Pilgrim Health Care (HPHC), a not-for-profit health insurance company serving 1,000,000 members in Massachusetts, New Hampshire and Maine has supported an ethics program that provides an important decision support function to the company. The program advises on clinical policies, insurance product development, and the full range of issues that contemporary health plans address. I have been responsible for the program since 2000.

Before HPHC launched the ethics program one of its two precursor organizations – Harvard Community Health Plan – had tip toed up to starting one several times but kept backing off. A major reason for the back pedaling was that a task force on “humanistic health care” in the 1970s had been perceived as a forum for grousing, and management was afraid that an ethics program might go down the same path. Management also feared that an ethics program might inadvertently take accountability for grappling with ethical problems away from program managers.

In 1995 Harvard Community Health Plan, a not-for-profit physician-governed HMO, and Pilgrim Health Care, a not-for-profit physician-governed IPA, merged to form HPHC. Despite their similarities, the cultures of the two organizations were different enough so that each felt the other might contain “unethical” components. HPHC started the ethics program to address these tensions.

The heart of the program is an ethics advisory group (EAG), composed of HPHC staff, consumers, physicians from the network, purchasers and brokers, and external ethics and health systems leaders. The group advises about issues brought to it by HPHC leaders (referred to as the “customer”) who are responsible for the area in question. Consultation with the EAG is always voluntary – it has no “must approve” role, and its opinions are advisory, not binding.

The every two month EAG meetings typically have twenty to twenty-five participants and last for two hours. I prepare and circulate a “case” in advance that gives background, identifies the customer’s questions, and summarizes relevant precedents. After the meeting I write a consultation report presenting the key perspectives that emerge from the deliberations. The report is posted on the HPHC intranet site and the Web site for affiliated providers. As of this summer the EAG has held 85 meetings.

The key question to ask about an organizational ethics program is – so what? What difference does the program make? There is no measuring rod for answering this question, but the leaders who bring questions to the EAG have been very positive about the experience and many have brought several issues to the group over the years. The meetings are open to HPHC staff and close to 10% have attended at least once, which the organization sees as a contribution to an organizational culture concerned with values and doing the right thing. Harvard Pilgrim has supported the program for eleven years, including during a financial crisis in 1999-2000 that required many cutbacks.

In this posting I want to give an example of how one organization has structured an ethics program. The question of whether and how ethics activities contribute to organizational effectiveness is the central focus of this blog, and I will speak to that topic recurrently in the future. I hope that over time readers will contribute observations from their own organizations.

The July/August issue of Health Affairs has a more extended article on the HPHC program: “Confronting Trade-Offs in Health Care: Harvard Pilgrim Health Care’s Organizational Ethics Program," written with David Cochran. If you would like a paper copy for educational purposes (Health Affairs does not provide a free pdf of the article yet) write to me at