Sunday, August 10, 2008

Hospital Ethics

On reason "ethics" has a bad name is the gap between espoused principles and the behavior of individuals and organizations. Highfalutin talk is one thing. Action on the ground is another.

Think of all the aphorisms. "Talk is cheap." "Actions speak louder than words." "You can talk the talk, but can you walk the walk?" When I teach ethics I often distinguish between analysis ("What is the right thing to do?"), advocacy ("Do the right thing!"), and administration ("Let's run things so we reliably do the right thing in the right way"). To be worthy of attention, the discipline of ethics requires attention to all three components. In organizations, the administrative component is necessary to make values real.

An article in today's Boston Globe told about a surgeon at North Shore Medical Center in Massachusetts who blew up when a scissors cut poorly and threw them, barely missing one of the nurses. In the past, outbursts of this kind have been overlooked, especially for busy surgeons who brought a lot of patients to the hospital. But in this instance the scissor-tossing surgeon was disciplined. Many other hospitals are doing the same. Operating room teams are being trained in teamwork, and policies are calling for "civility and respect."

Since this was always the right thing to do, what's changed? The change appears to be recognition of the link between civil behavior among team members and patient safety. When the ethical calculus involved weighing respectful team behavior against potentially angering a high-producing surgeon, hospital administrators tilted towards ignoring bad behavior. But when research showed that team conflict increased medical errors, the scales tilted towards confronting the behavior.

There are two important lessons here.

First, it's easy to say that abusive behavior in an operating room team is disrespectful, and therefore wrong. But on its own, that argument accomplished nothing. Administrators felt the risk of alienating surgeons and losing their business outweighed respectful team behavior. Their conclusion is understandable. If the hospital didn't have patients to care for it would go down the tubes. No margin, no mission.

Demonstrating the link between team cohesiveness and patient safety made the equation come out differently. Medicine is about results. It is a very consequentialist field. The principle of "civility and respect" took on more weight when eruptive operating room behavior came to be seen as a cause of worse outcomes.

Second, North Shore Community Center took the administrative side of ethics seriously. It didn't just send out a memo saying "we should treat each other with civility and respect..." It followed through, with training and discipline. Without this kind of administrative follow through, staff become cynical about moral pronouncements and "ethics."

To be worth its salt, organizational ethics needs to bring analysis, advocacy, and administration together. We physicians often badmouth administration, but without it professional ideals are just words.