The Ethical Life of Health Care Organizations

Institutions have ethical lives and characters just as their individual members do. Health care organizations must look critically at how professed institutional values can best be realized in day-to-day interactions within the institution and with the wider community. While organizations nave had a long history in die life of health care, during the twentieth century they have achieved an unprecedented dominance. Individual decision-makers increasingly are being supplanted by the rules, standards, traditions, and collective decision process of organizations, which instruct and construct institutional actions in shaping health care choices. As their authority has grown, these organizations have not given adequate attention to the essential associations that exist among their constituents, to the values generated and used in their interactions, or to the role of the organization itself in fostering humaneness in the relationships and environment of the workplace. This article addresses these issues, focussing especially on academically affiliated institutions. It demonstrates the connections between policymaking and human man values in health care organizations. It calls for a major exploration of the values determining their actions, comparable to the fundamental reappraisal by modern clinicians of the ethics governing their individual practices, and commensurate with the authority and responsibility of organizations in health care today. Organizational Ambivalence about Values and Purposes The main institutions of health care - hospitals and professional schools - have traditions that focus on the ethical dimensions of their actions. Hospitals, an innovation of the early Christian church to assist the needy who were sick, are rooted in a religious and philanthropic tradition.[1] Their literature reflects this history, and in the contemporary period hospitals have made advances in this area, such as the American Hospital Association's Patient's Bill of Rights that enumerated the ethical responsibilities of hospitals to patients,[2] which in turn spurred some hospitals to compose codes of ethics to guide their actions.[3] During the 1980s and into the 1990s, many hospitals developed mission or vision statements, vehicles that identified guiding organizational purposes and goals, and that management experts recommended as crucial ingredients of institutional leadership.[4] So too in recent years some professional schools and the academic health centers into which they are increasingly integrated have written codes of ethics,[5] and many have produced mission and vision statements. However, the efforts of health care organizations in this area are episodic and lack the comprehensiveness needed to deal with the complex isssues they now must face. Of these issues, the contradiction between the behaviors organizations urge and the actions they take is pivotal. For instance, clinicians at a medical school may lecture to students on the need to treat patients who are indigent in the same way as those who are not, while turning over the day-to-day care of indigent patients to residents. Similarly, administrators at the institution may build facilities for affluent patients while neglecting the poor in the neighborhood that surrounds it. Instructors in class may lecture students on the need to treat patients with dignity, while students in their daily experiences with residents, professors, and administrative personnel may be treated perfunctorily, without their feelings considered or needs met. Organization leaders may call for coperative work, while bitterness displayed in controversies among faculty (the disruptive politics of the academic world) and antagonism between like institutions (the intense marketplace battles of the hospital world), remain basic features of organizational life. Yet organizations declare what really counts by their treatment of staff, students, and community, the institutional goals they set, and how they handle controversy and conflicts. …