Ethical Challenges in Veterans Administration Healthcare Facilities

The April issue of the American Journal of Bioethics has a valuable piece of ethics research from the VHA.

To understand the challenges faced by Veterans Administration facilities, the authors conducted focus groups with patients (32) and managers (38), and semi-structured interviews with managers (31), clinicians (55) and ethics committee chairpersons (21). They found that all parties were deeply concerned about the ethics of the enterprise. There was no evidence whatsoever to support the common view held by clinicians that they are concerned with values while bureaucratic "beancounters" are concerned with business and the bottom line.

But the issues that most concerned the groups varied:

• Managers worried about how to distribute resources fairly among the different components of the facility and what kind of process to follow in doing this.



• Clinicians worried about providing high quality care with limited resources and balancing duty to patients with the obligation to be stewards of VA resources.



• Ethics committee chairs were most concerned with improving end-of-life care and ensuring that patient preferences were honored.



• Patients had as their top priorities receiving respectful and caring treatment from all staff and improving service quality.

The good news for those concerned with strengthening the culture of ethics at health care organizations is the fact that everyone saw health care as a value-driven mission. The bad news is the danger that health organizations could become Towers of Babel, with all groups speaking about ethics and values but unable to communicate with each other.

The VHA National Center for Ethics in Health Care has developed and is beginning to implement a very promising approach to the Tower of Babel danger - the IntegratedEthics program.

Anyone interested in the ethics of organizations should read the 15 page VHA report. Page 5 of the report has a useful picture of an "ethics iceberg." At the surface are the visible decisions and actions that are carried out every day - respecting/not respecting patient preferences, returning/not returning telephone calls, etc. Immediately under the surface are the organizational systems and processes that shape decisions and actions - such as ethics consultation, staff education and supervisory systems. At the deepest level, least directly observable but most powerful, is the ethical environment and culture of the organization.

What's most distinctive about the VHA approach is the way it links components of the organization that usually live in separate silos. In my teaching about ethics I've used the heuristic device of 3 "As" to describe the components of ethics in organizations. The VHA conception suggests a practical way to make them work together:

• Analysis (What's the right thing to do?) Ethics committees/ethics consultation concentrate on answering these analytical questions.



• Administration (How do we make it easier to do the right thing?) This is the responsibility of the various components of operations management.



• Advocacy (Let's make sure that we all embrace the same values and ideals.) This is the values leadership for which the CEO and her team are crucial.

The IntegratedEthics program envisions these ordinarily disparate functions being brought together in a managerially coordinated way. It's a smart, practical and promising approach to improving the ethics of organizations.