BY: RON HAMEL, Ph.D.
Dr. Hamel is director, department of clinical ethics, Lutheran General Hospital, Park Ridge, IL. This article is adapted from his Connery Lecture at the Archdiocese of Chicago Convocation for Health Affairs, October 1996.
What Does Ethics Contribute To the Life And Work Of an Organization?
Summary
In faith-based healthcare, the scope of ethics reaches beyond clinical ethics—which, up to now, has been its primary focus—to encompass the entire culture of the organization and all its relationships. Consequently, sustained attention to ethics contributes to the life of, and adds value to, the organization.
Ethics' role is to articulate the beliefs and values that are to be embodied in the organization's culture, given its fundamental commitments. Ethics devises methods for shaping and nurturing the culture, and has a role in periodically assessing the state of the organization's culture. Ethics is also part of the organization's relationships, both external—with other healthcare entities, the community, and society—and internal—with employees and patients. Further, ethics shapes the relationships the organization's associates have with each other and with the organization.
Attention to ethics encourages improvement in the moral quality of the interactions within the organization; provides an opportunity for moral growth; creates a climate in which ethical issues are dealt with, not ignored; and, over time, creates a community of moral discourse.
It may seem odd to ask about the value of ethics in faith-based healthcare. Surely, one assumes, ethics is naturally valued in such an environment. But the question is an important one, because a lack of clarity about the role that ethics can and should play in our healthcare organizations may not only diminish the significance of ethics, but might lead some to think that formal and consistent attention to ethics is not essential to the successful operation of a healthcare facility or system.
So the question remains: What really is the value of ethics? Since it rarely, if ever, directly generates significant revenue, what does it actually contribute to the life and work of an organization?
What "Faith Based" Means
To appreciate the place of ethics in faith-based healthcare, we must first consider what it means to be a faith-based healthcare organization, a question that many healthcare entities are grappling with in today's tumultuous healthcare climate. Being faith based must go beyond being church related or displaying religious symbols; it must even go beyond mission, values, and philosophy. To be faith based means to be grounded in, and guided by, the fundamental beliefs and values of a particular faith tradition—to be committed to and informed by its core elements. This rootedness leads to a particular way of being and doing, one that arises out of, is consistent with, and expressive of the faith stance.
The challenge to faith-based healthcare is to determine which of its tradition's core beliefs and values will shape its identity. Catholic healthcare, in addition to seeing healthcare as a continuation of the ministry of Jesus, has focused on several biblical values as distinguishing characteristics: respect for the dignity of the person, stewardship, an option for the poor, concern for community, and the common good. Card. Joseph Bernardin, in his October 1995 pastoral letter A Sign of Hope, offered yet another faith-based perspective that should distinguish Catholic health ministry. He says: "The ultimate goal of our care is to give to those who are ill, a reason to hope. . . . Although illness brings chaos and undermines hope in life, we seek to comfort those who are ill, whether or not they can be physically cured. . . . In this we find the Christian vocation that makes our healthcare truly distinctive."
An organization cannot be truly faith based if the statements that define it have little relationship to the grounding faith events and faith tradition. Even more important, the culture of the organization must be shaped by and reflect the faith stance, as must its policies and procedures. Last but certainly not least, the behavior of the institution as a whole and all its members, from the CEO and the chairman of the board to the housekeeping staff and volunteers, must reflect the core beliefs and values of the faith tradition that have been designated in the organization as distinguishing the ministry of healing. Does this mean that everyone in the organization must espouse its faith stance? No. But everyone must be willing to embody its fundamental values.
Connecting Faith and Ethics
Ethics is intimately related to faith. It articulates the practical implications of faith for how one behaves. But it is also concerned with character formation—cultivating beliefs, values, attitudes, affections, virtues, and intentions emanating from the faith stance. In faith-based healthcare, ethics reaches beyond clinical ethics—which, up to now, has been almost its exclusive focus—to encompass the entire culture of the organization and its behavior externally and internally.
Shaping the Culture The culture of an organization consists of the beliefs, values, and practices to which it is committed and which become embodied in the way the institution operates at all levels. Shaping this culture must be a deliberate activity. This is especially true of faith-based healthcare organizations because many of their core beliefs and values are not those that prevail among the general public, in the marketplace, or in medicine.
First, ethics' role is to articulate the beliefs and values that are to be embodied in the organization's culture, given its fundamental commitments. Second, ethics devises methods for shaping and nurturing the culture. This is perhaps the most difficult challenge—to find ways for the core values to permeate all aspects of the organization. And, third, ethics has a role in periodically assessing the state of the organization's culture.
Relationships, Inside and Out
Healthcare organizations engage in many relationships beyond those involving patients and their families, but ethics in healthcare has not attended to ethical issues in these areas with the same focus and intensity that it has to ethical issues in patient care. These are areas, however, in which ethics must play a role, especially in faith-based institutions. It is these areas that test the breadth and depth of the organization's fundamental commitments.
Looking Outward Externally, we can point to at least three publics with which a healthcare organization interacts. One consists of other healthcare entities—hospitals, systems, physician groups, long-term care facilities, insurance companies, vendors, and others. This is the realm of business ethics.
The healthcare organization also interacts with its local community. Interactions may range from addressing community health needs to dealing with building, landscaping, parking, and traffic issues. This is the realm of social ethics.
A third public with which healthcare organizations relate is society at large. Just as individuals have a moral responsibility to promote the common good, to pursue justice, and to practice good stewardship, so do organizations. Medicaid reimbursement, the organization of Medicaid and Medicare, the provision of healthcare to the uninsured and underinsured, the legalization of physician-assisted suicide, the utilization of healthcare resources—these are all examples of ethical issues in this arena. This, too, is the realm of social ethics.
Looking Inward Internally, we can identify at least two publics with which the organization relates: its own employees and patients and their families.
The primary way in which an organization relates to its employees is through its structures, policies, and procedures. Do these reflect the faith-based character of the organization? Are the fundamental commitments of the organization evident in salaries and benefits, in the way associates are hired and fired, and in the way downsizing occurs? To what extent are respect for persons and justice embodied in the policies, procedures, and practices of the organization as they relate to its associates? These issues fall under the umbrella of organizational ethics, which includes business ethics.
Also important is the relationship of the organization to its patients and their families. Does it provide quality care at fair prices? Does it provide a welcoming environment? Does it meet patients' and families' needs? Do all members of the organization treat them with respect and compassion? The countless ways in which an organization relates to patients and their families are countless opportunities for embodying the institution's faith-based values.
Associate Relationships On another level, ethics can also shape the interactions the organization's associates have with one another, with patients, and with the organization itself. Does the ethos of the organization support mutual respect among its associates? What does the organization do to promote its values through the myriad human relationships and interactions that occur daily within the organization?
Finally, ethics in faith-based healthcare should be concerned with how associates relate to the organization. What are their moral responsibilities? How should they promote the good of the organization and fulfill its mission? Ethics can help spell out these responsibilities and assure that they are in accord with the faith-based character of the organization. Organizations may want to formulate a statement of "Employee Rights and Responsibilities."
Paying Attention to Ethics
Because ethics has a bearing on the entire culture of the organization and on all its relationships, explicit and sustained attention to ethics inarguably contributes to the life of, and thus adds value to, a faith-based organization.
- Attention to ethics heightens awareness of the ethical dimensions of the organization's life and communicates the message that the institution cares about what it is and what its members do. It encourages continual improvement in the moral quality of the various interactions that occur at the organizational and individual levels.
- Attention to ethics can significantly improve the moral agency of the members of the organization, whatever their responsibilities. It helps them to become more aware of their own values and how they compare to those of others and the organization. This awareness can lead to a reexamination of personal values and provide an opportunity for moral growth.
- Attention to ethics can help members of the organization become comfortable with addressing ethical issues. It creates a climate in which ethical issues are dealt with instead of ignored.
- Attention to ethics, over time, creates a community of moral discourse. It provides opportunities for people to exchange views on issues that are of concern to them, gain information and new insights, and receive guidance in how to address these issues. It supports serious ethical reflection. All of this, in turn, can change practice. It can affect the way the organization operates and the way people act. Furthermore, such a community of moral reflection, tackling difficult ethical issues in healthcare, can position the organization to take a leadership role within the healthcare community.
Making It Happen
How can faith-based healthcare organizations achieve an explicit and sustained attention to ethics, if it doesn't already exist?
- Top-level administrators must be committed to ethics and communicate this commitment often to all levels of the organization.
- The scope of ethics within the organization must be broad. Ethics encompasses interpersonal issues, business issues, institutional issues, and societal issues as well as medical issues. Every aspect of the institution's life is of ethical concern.
- Someone must be responsible for the endeavor. This could be a trained ethicist or someone who has other responsibilities but who also possesses a knowledge of ethics. But the responsibility for ethics should not be relegated solely to this individual. Ultimately it is the responsibility of everyone within the institution.
- Attention to ethics must be consistently visible. Mechanisms for addressing ethical issues include an ethics newsletter; periodic case conferences in which clinical, business, and organizational cases are considered; a "journal club" that meets to discuss articles in ethics journals; a noon-time lecture series that focuses on ethical topics; and a day or half-day dedicated to ethical topics.
The Bottom Line
Ethics is essential to realizing the mission, values, and philosophy of organizations that claim to be grounded in a faith tradition and a faith stance. Ethics goes a long way in helping such organizations realize their distinctiveness in every dimension of organizational life. It can make a profound difference in shaping the identity and the behavior of the organization and its members.
Is explicit and sustained attention to ethics of any value? It is difficult to imagine a time when it would be of more value. So much of what faith-based healthcare stands for is being challenged by what is going on in healthcare itself and in society. Faith-based healthcare has an opportunity to offer a different perspective and a different way of doing things.