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BY: RON HAMEL, Ph.D.

Dr. Hamel is senior director, ethics, Catholic Health Association, St. Louis.

Recently, I overheard a leader from a Catholic hospital make the comment: "I think our organization is very ethical. We're extremely diligent about following the ERDs (Ethical and Religious Directives for Catholic Health Care Services)." The statement struck me. For starters, I wondered who the "we" was. Did the "we" extend to everyone from housekeeping to the clinical staff to administration? Was everyone diligent about following the ERDs? And to what in the ERDs was this leader referring — to the beliefs and values in the Introductions or only to the directives? If only the directives, was it the full range, some, or only those having to do with prohibited procedures? The breadth and depth of observance was not clear.

I walked away wondering whether, in this leader's mind, adherence to the directives themselves is sufficient to make a Catholic health care organization ethical. Surely it is a necessary part. But sufficient? Was this leader equating "being ethical" with being guided by principles and abiding by prescriptions and proscriptions, unwittingly reducing ethics to compliance? Or did this leader understand that being ethical has as much to do with who we are and become as individuals and organizations as with what we do? The culture, or the identity and character, of an organization is as essential to its being ethical as its behavior.

Interestingly, the U.S. Department of Veterans Affairs is engaged in a concerted effort to move beyond a singular focus on "right behavior" (which risks a focus on compliance) to shaping the culture and environment that support right behavior, even in those situations where there are no specific rules or guidelines to follow. Through its National Center for Ethics in Health Care, the VA is implementing a three-pronged systems-focused model called IntegratedEthics to improve ethics quality in its facilities.¹ The model addresses three levels all of which contribute in some way to ethics quality — decisions and actions, systems and processes, and environment and culture. It is this latter element that flashed into my mind when I heard the comment by the health care leader.

The core to the VA's initiative is the fostering of an ethical environment and culture within an organization.² "This deepest level of organizational values, understandings, assumptions, habits, and unspoken messages" — what people in the organization know but rarely make explicit — "is critically important since it is the foundation for everything else."³ What it has in mind is different from an organizational environment and culture that emphasizes only adherence to rules. As the VA explains it:

"Rules usually define prohibited behavior or minimal standards, instead of inspiring exemplary or even good practices. … From an ethics perspective, overemphasizing rules can lead to 'moral mediocrity' — or worse, unethical practices, if employees equate 'no rule' with 'no problem' or if they 'game the rules' by developing ethically problematic workarounds.

"While employees in rules-driven organizations tend to concentrate on what they must do, those in organizations with a healthy ethical environment and culture tend to concentrate more on what they should do — finding ethically optimal ways to interpret and act on the rules in service of the organization's mission and values."⁴

From the VA's perspective, leaders have a critical role in creating, sustaining and changing their organization's culture. They do this through their own behavior as well as by communicating what they consider to be important or unimportant, what they support and praise or neglect and criticize. Hence, the focus of the third leg of the VA's model is promoting "ethical leadership," by which it means "activities on the part of leaders to foster an environment and culture that support ethical practices throughout the organization."⁵ But the ultimate goal is to achieve ethics quality which seeks to ensure that "practices throughout an organization are consistent with widely accepted ethical standards, norms, or expectations for a health care organization and its staff — set out in organizational mission and values statements, codes of ethics, professional guidelines, consensus statements and position papers, and public and institutional policies."⁶

In an analogous model, Catholic health care would add the "core commitments" of Catholic health care as well as the ERDs.

And what does the VA consider to be an ethical environment and culture?7 Where such an environment and culture exists, it maintains, members of the organization:

• Appreciate that ethics is important.
• Recognize and discuss ethical concerns.
• Seek consultation on ethics cases when needed.
• Work to resolve ethics issues on a systems level.
• See ethics as part of quality.
• Understand what is expected.
• Feel empowered to behave ethically.
• View organizational decisions as ethical.

Leaders, the VA proposes, shape the culture of the organization through their words and actions.⁸ The following are determined to be especially important:

• What leaders pay attention to, measure and control on a regular basis
•  How leaders react to critical incidents and organizational crises
•  Observed criteria by which leaders allocate resources
•  Deliberate role modeling, teaching and coaching
•  Observed criteria by which leaders allocate rewards and status
•  Observed criteria by which leaders recruit, select, promote, retire and ostracize organizational members

Finally, the VA suggests four behaviors through which leaders can foster an ethical environment and culture.⁹ Leaders can:

• Demonstrate that ethics is a priority by talking about ethics, proving that ethics matters personally, and encouraging discussion of ethical concerns.
• Communicate clear expectations for ethical practice by recognizing when expectations need to be clarified, being explicit, giving examples, and explaining underlying values, as well as anticipating barriers to meeting the leader's expectations.
• Practice ethical decision-making by identifying decisions that raise ethical concerns, addressing ethical decisions systematically, and explaining the reasoning behind decisions.
• Support your local ethics program by knowing what your ethics program is and what it does, championing the program, and supporting participation by others.

What becomes fairly obvious from this segment of the VA's IntegratedEthics initiative is that fostering an ethical culture is an intentional activity and that leadership is intimately involved in that process. As the VA puts it: "An ethical environment and culture don't just happen spontaneously; they must be developed and nurtured. Leaders need to treat ethics the same way they treat other organizational priorities."¹⁰ Within a Catholic health care context, promoting adherence to the ERDs is essential, but not sufficient. Most leaders recognize this. And Catholic health care is surely committed to fostering and strengthening an ethical environment and culture. This is one of the primary roles of ethicists and mission leaders.

Nonetheless, several things are remarkable about the VA's efforts. One is the comprehensiveness of the approach. A second is the obligatory nature of the endeavor. All institutions within the VA are obliged to implement it and leaders are held accountable. Another is that the VA places the primary responsibility for fostering an ethical culture with the organization's leaders. It is regarded as one of their primary responsibilities as leaders. Finally, and perhaps most important, it is striking that the VA has taken ethics and ethics quality so seriously and seeks to integrate them throughout its organizations. Perhaps there is something here to be learned.¹¹  

NOTES

1. National Center for Ethics in Health Care, published report, IntegratedEthics: Improving Ethics Quality in Health Care (Washington, D.C.: U.S. Department of Veterans Affairs, 2007). Available online at www.ethics.va.gov/IntegratedEthics.
2. National Center for Ethics in Health Care, published report, Ethical Leadership: Fostering an Ethical Environment & Culture (Washington, D.C.: U.S. Department of Veterans Affairs, 2007). Available online at www.ethics.va.gov/IntegratedEthics.
3. Ethical Leadership: Fostering an Ethical Environment & Culture, 4.
4. Ethical Leadership: Fostering an Ethical Environment & Culture, 3.
5. Ethical Leadership: Fostering an Ethical Environment & Culture, ii.
6. Ethical Leadership: Fostering an Ethical Environment & Culture, 2.
7. Ethical Leadership: Fostering an Ethical Environment & Culture, 14-16.
8. Ethical Leadership: Fostering an Ethical Environment & Culture, 17-19.
9. Ethical Leadership: Fostering an Ethical Environment & Culture, 21-xx.
10. Ethical Leadership: Fostering an Ethical Environment & Culture, 19.
11. Recently, Kaiser Permanente of Oakland, Calif., announced an integrated ethics approach in its facilities in southern California and is in the process of hiring staff ethicists for 12 service areas. The organization is explicitly linking ethics and quality improvement with the goal of being "much more effective in being able to promote ethical practice" (Medical Ethics Advisor, October 2008, p. 111). Also, the organization is seeking ethicists with at least master's degrees with starting salaries at $150,000. This initiative suggests a strong commitment to ethics and to ethics quality.