Thursday, June 5, 2008

Hospital Organizational Ethics

The Journal of Medical Ethics recently published an interesting study from the University of Toronto Joint Centre for Bioethics - "Clinical Ethicists' Perspectives on Organizational Ethics in Healthcare Organizations."

The authors interviewed clinical ethicists at eight academic hospitals, four general hospitals, and one community-based care agency in the Toronto area. The participants were asked about the organizational ethics issues their organizations were facing, how these issues were being addressed, and how effective the process was.

The participants identified four major organizational issues:

1. Resource allocation. Canadian hospitals are financed by global budgets negotiated with the provincial health plan. A fixed budget highlights trade off decisions. The ethicists identified having a fair process - a topic my colleague Norman Daniels and I have written about extensively - as a key organizational need. One interviewee commented:
"How do we make decisions about resources in terms of money, as well as staff, and how do other resources get distributed? What model or models of distributive justice or resource allocation...ought we to be considering."
2. Moral distress and organizational moral climate. In the research and consultation I have done, questions like "what keeps you up at night?" and "what do you feel best...and worst about in your work?" have been very productive. Moral distress isn't an infallible sign of an organizational ethics issue. Lucifer was distressed by the conditions in heaven, but that is taken reflect moral failing in Lucifer, not heaven. But investigating moral distress will have high yield for identifying ethical hot spots in an organization.

The ethicists identified seven factors contributing to a positive moral climate: alignment of decisions with the hospital's stated values; transparency about management processes, decisions and actions; staff involvement in organizational decision-making; opportunities to raise difficult ethical issues safely; public recognition of admirable achievements; respectful relationships among staff; and fair employment practices.

3. Conflict of interest. Interestingly, the ethicists felt that by and large the hospital policies on financial conflicts set limits on monetary conflicts, and that non-finacial conflicts - prestige, personal advancement, etc were more problematic.

4. Clinical issues with a significant organizational dimension. Clinical ethicists and clinical ethics committees are increasingly encountering major organizational components to issues that are defined as "clinical." The examples cited include decisions about access to care for uninsured patients, decisions related to disclosure of medical error, and a range of issues arising in end-of-life care.

The authors conclude that "the extent to which 'clinical ethics' cases were embedded with an organizational dimension...suggests that the common distinction between clinical and organizational ethics may be overdrawn in the practice of direct patient care...Where once the clinical ethicist's role focused primarily on ethics in discrete clinical or research relationships, its focus is expanding to include ethics in a broader range of organizational relationships and issues."

That's the reason I started this blog!