BY: ED GIGANTI
Mr. Giganti is senior director, ministry leadership development, Catholic
Health Association, St. Louis
Among the characteristics of effective leaders in the health ministry described
in the Mission-Centered Leadership Competency Model* is the profound courage
to act on one's values and take risks consistent with those values. This
competency of integrity, which pairs with the competency of spiritual grounding
in the model's Vocation Cluster, includes the struggles and challenges
that inner spiritual life undergoes as it seeks to express itself in action.
Integrity becomes the personal basis for integrating the values and mission
of Catholic health care with the business realities of the marketplace.
* For more on the Mission-Centered Leadership Competency
Model, see "Assessing
and Developing Leadership"
Leaders demonstrating this competency act from their values even when it is
difficult, risky, or costly to do so, and these leaders, when performing at
the highest level of this competency, create environments that nurture integrity
in the others who minister with them.
The leader, it would seem, must be the primary agent of organizational integrity,
right? Not exactly, Ann Neale, PhD, told the capacity audience in her presentation,
"Organizational Ethics: Corporate and Mission Issues" during the March
program, "Ethics in Health Care: The Catholic Perspective".
"The character and integrity of the organization is not simply the aggregate
of the moral agency of the individuals it employs," said Neale, who is
senior research scholar at Georgetown University's Center for Clinical
Bioethics, Washington, DC. Of course, ethical behavior ultimately is enacted
by individuals, but understanding the complexity of organizational ethics requires
a more comprehensive assessment.
Moral Individuals Won't Suffice
"Health care executives and workers should surely be morally upright
individuals," Neale said. "Their being such, however, is no guarantee
of their organization's moral integrity. Rather, an organization's
moral integrity is evidenced in its policies, practices, and relationships,
that is, in a moral posture that is not only distinct from the moral agency
of management, medical staff, and employees, but that, in effect, transcends
those individuals' moral agency."
Culture, Neale said, is a shorthand label for the character and moral
agency embodied in the organization's infrastructure. It is made up of
the assumptions, beliefs, and values that drive the organization. Organizational
culture is built up, over time, from the decisions of individuals and the organization's
interactions with the surrounding cultural ethos in which it lives.
A morally deficient organizational culture can prevail despite the intentions
of morally upright managers, Neale said, just as a morally robust organizational
culture can survive the moral weaknesses of individuals, even key leaders. "The
organization's culture is not something that individuals can easily or
quickly change, even individuals with excellent leadership skills," she
said. (Conventional wisdom says it takes a leader at least six years to affect
an organization's culture.) "That is because the moral character of
an organization is an accumulation, from multiple sources, of attitudes, behaviors,
and influences. Over time, the organization's management, clinicians and
other staff, its trustees, and societal forces, especially the market,
have shaped the way it understands and lives out its mission."
Neale's concern is that an emphasis on the individual as moral agent can
give the impression that the personal moral integrity of the leader is tantamount
to organizational integrity. This perspective fails to recognize the distinction
between the ethical dimension of an institution's policies and practices
and the moral uprightness of individual leaders. "Americans regard individual
persons as the primary element of moral concern," Neale said. "This
thinking can reinforce an ethical individualism which sees persons as radically
independent, utterly self-reliant." What may be missed, she added, is the
influence, and possibly even control, that organizations and the larger culture
have on an individual's moral freedom.
"Systems Thinking" Is Needed"
To invoke the inspirational rhetoric of mission and values in a framework that
is focused on individual moral agency does not do justice to the complex moral
terrain in which individuals in the ministry operate," she said. What is
needed, she told the audience, is a "systems thinking" approach to
ethical issues. "Health care ethics is a type of systems thinking. It offers
a framework that takes into account the connections among its various systems
and understands their effects on one another."
As an example, she applied this systems thinking to the issue of providing
good end-of-life care. Care at life's end that witnesses to God's
love and compassion would be characterized by decisions reflecting the patient's
values; an emphasis on pain and symptom relief; attention to alleviating the
patient's and family's suffering; spiritual counseling; treatment
decisions that demonstrate good stewardship of resources; and a recognition
that care, not cure, is the goal. A systems thinking assessment of this issue,
however, identifies realities of inadequate education in end-of-life care and
a medical model—and its reward and incentive systems—that values cure
over care. In such an environment, Neale said, it is unrealistic to place the
sole burden for improved end-of-life care on individual moral agents. "Exhortations
to individuals about good end-of-life care need to be accompanied by strategies
to change the culture of medicine that perpetuates poor practice, to educate
the public, to influence public policy.
"We would make more ‘moral' progress if we recognized the limits
of individual moral agency and more carefully distinguished which dimensions
of the issue required a moral response from the organization and/or society,"
she continued. A systems thinking approach to health care ethics recognizes
the individual, organizational, and societal realms of ethics and the mutual
relationships among them, she said. Such an approach involves a more nuanced
appreciation of moral responsibility and more effectively addresses health care
dilemmas in all their complexity.
Neale described this systems thinking approach as reflecting the "three
realms of ethics" named by John W. Glaser, STD, senior vice president,
theology and ethics, St. Joseph Health System, Orange, CA, and author of Three
Realms of Ethics (Sheed and Ward, 1994). In visualizing the three realms
as nested—the individual realm in the organizational, the organizational
realm in the societal—the framework highlights the significant influence
the societal realm has over the other two. "For instance, because the market
reigns supreme in our culture, the prevailing cultural value is profit,"
Neale said. "Most of us in health care have experienced the influence of
the market on both our own moral agency and that of our organizations. Who,
in advocating for the medically underserved, has not tempered her idealism because
of market realities?"
But ultimately, the pressure of the societal realm does not absolve individuals
or organizations of moral responsibility, Neale said. "Since the mission—to
be signs and agents of God's love and compassion—remains, and since
the individual or organizational freedom to be and do such is constrained, both
individuals and organizations are obliged to advocate for structural changes
in the societal realm," she said. "Individuals and organizations have
a moral responsibility to effect social change because the mission depends on
it."
No "Ethics-Free Zones"
In the life of the Catholic health care organization, there are no "ethics-free
zones" because virtually every organizational function has an impact on
human dignity. "The organization is a vehicle, which through its organizational
functions is accomplishing the mission," Neale told the audience. "The
mission is not something other than what the organization does. In performing
everyday functions in accord with its vision and values, the organization is
sign and agent of God's love and compassion. Organizational integrity,
then, is the way the ministry continues Jesus' mission of radical healing."
About the Conference
The conference at which Ann Neale spoke, "Ethics in Health Care: The Catholic
Perspective," was cosponsored by CHA and the Neiswanger Institute for Bioethics
and Health Policy at the Stritch School of Medicine of Loyola University Chicago.
It was held March 3-5, 2004, in Chicago. More than 150 people attended the two-and-one-half-day
conference and heard presentations by Fr. Kevin O'Rourke, OP, JCD, the
conference director, and a faculty of noted ethicists from Catholic health care,
including CHA's senior director of ethics, Ron Hamel, PhD. CHA and the
Neiswanger Institute will cosponsor a similar conference March 2-4, 2005, at
the medical school campus in Maywood, IL.
Neale is the author of the online document, Organizational
Integrity in Catholic Healthcare Ministry: The Role of the Leader.