A System's Corporate Ethics Committee Assesses Its Accomplishments and Future Direction
Sr. Sullivan is director, public policy, and Sr. Egan is vice president, mission services, Sisters of Mercy Health System, St. Louis.
Summary
In 1992 the Sisters of Mercy Health System (SMHS) Corporate Ethics Committee (CEC) developed a three-step evaluative process of the system's ethics programs. The evaluation consisted of a retrospective review of the minutes of CEC meetings since the committee's inception, an oral evaluation with current CEC members, and a written assessment of the committee's performance by current and former members.
In the open discussion, 86 percent of participants indicated that the system needs the CEC because it facilitates in-depth examination of ethical issues and provides important research and consulting services to the system executive. Respondents completing the written evaluation indicated that the CEC's dominant strength is the diversity of its membership, which includes trustees, physicians, ethicists, nurses, administrators, managers, and chaplains.
More than 57 percent of respondents reported the CEC has achieved all six of its goals, which included education, articulation, decision making, policy development, program development, and evaluation.
A review of the CEC evaluation suggests that the committee has moved beyond the development stage and entered a period of active growth. CEC members have made great strides in educating themselves, and the committee must now consider whether to broaden its focus by developing its knowledge base and skills for bioethical education and policy recommendations. The CEC is currently testing an ethical decision-making model it recently developed.
The function of ethics committees within an organization is often a matter of dispute. Although their role in staff education and policy development is generally recognized, many question whether they should have an active voice in case review and decision making. Some critics suggest that ethics committees may "over-bureaucratize" decision-making processes and that they are prone to domination by a single professional viewpoint.
Aware of the controversy over ethics committees' roles and of the lack of rigorous methods of evaluating their effectiveness, in 1992 the corporate ethics committee (CEC) of the Sisters of Mercy Health System (SMHS), St. Louis, developed a process for evaluating the system's ethics programs.
Comprehensive Ethics Program
SMHS developed its comprehensive ethics program in 1987 in response to a mandate embodied in the system's mission and vision. The system's resources for strengthening ethical decision making and action include the CEC, institutional ethics committees (IECs), and prepared ethicists. The CEC considers comprehensive ethical issues for the system, while the IECs address similar issues faced by system members. Ethicists at a number of system facilities educate staff on ethical issues, provide consultation, aid in policy development and planning, and conduct research.
CEC Evaluation
The CEC evaluation involved three steps: a retrospective review of the minutes of CEC meetings since the committee's inception, an oral evaluation with current CEC members, and a written assessment of the committee's performance by current and former members.
Retrospective Review The activities reported in the minutes, along with the SMHS policy for its comprehensive ethics program, served as baseline information for developing the CEC questionnaire. Three members of the CEC reviewed the document for content validity before it was distributed. The questionnaire gathered data indicating how effectively the CEC had achieved the goals it had established in 1987 (see "The Widening Scope of Healthcare Ethics" at the end of this article) and the direction it should take in the future. It included check-off and open-ended questions related to members' assessment of the CEC's purpose, goals, dynamics, accomplishments, and future direction.
Oral Evaluation
Fourteen current CEC members discussed their responses to the questionnaire and participated in the written evaluation as well. In the open discussion, 86 percent of participants indicated that the system needs the CEC because it facilitates in-depth examination of ethical issues and provides important research and consulting services to the system chief executive officer (CEO). In general, members agreed that serving on the committee had improved their ethical decision-making ability and that the committee itself has potential for greater influence within SMHS, particularly with regard to IECs.
Written Evaluation
Twenty-one persons (81 percent of current and past CEC members) completed the questionnaire. Respondents indicated that the CEC's dominant strength is the diversity of its membership, which includes trustees, physicians, ethicists, nurses, administrators, managers, and chaplains. When asked what professional traits or backgrounds brought the greatest strength to the committee, eight said the CEC benefits from the multiple talents, real-world experience, and expertise of this combination of individuals.
Roles The three-stage evaluation process indicated that the committee believes that it advises the system CEO "very much" in clinical areas, "a lot" to "somewhat" in social areas, and "least of all" in business areas. Thirty-eight percent of respondents rated CEC overall as excellent, 43 percent as good, and 10 percent as fair. (The remaining 9 percent did not respond.)
Goals More than 57 percent of respondents reported the CEC has achieved all six of its goals (see "SMHS Corporate Ethics Committee Goals" at the end of this article). They ranked education as the most relevant of the committee's goals, followed by articulation, decision making, policy development, program development, and evaluation.
Individuals commenting on the relevance of the CEC goals frequently mentioned the challenge of applying Judeo-Christian and Catholic ethical principles in changing and difficult circumstances. Some stressed the importance of clarifying the system's goals and concerns to educate others about these issues. Other respondents suggested that the CEC focus more on business ethical issues and seek input from member facilities concerning relevant ethical issues.
Key Issues
Healthcare reform and AIDS were identified by 90 percent of respondents as the major issues requiring the attention of the system and its members. End-of-life issues and rationing were viewed as critical areas of concern for the system, whereas more clinical issues such as artificial hydration and nutrition and ventilator support were identified as central to local facilities.
Respondents suggested that issues related to genetics and the human genome project might be a focus of ethical reflection at the system level. Several also raised concerns about the need to address ethical issues in rural healthcare settings. Some respondents questioned whether hunger, homelessness, and other social issues would be better approached through advocacy efforts than in ethics committees.
Group Dynamics The range of service for CEC members was from 1.5 years to 7 years; members served an average of 3 years. More than 50 percent of respondents believed that the CEC should not limit length of service because members needed time to "work effectively," "gain expertise," and "develop and see projects through." However, 38 percent thought length of service should be limited "to allow for fresh thinking and learning" and "to give people time to contribute."
Thirteen of the respondents saw the opportunity to clarify ethical issues for themselves and others as the greatest benefit of serving on the CEC; eight others said their own ethical decision making improved as a result of their experience on the committee. Other benefits mentioned included "increased confidence in working with patients and their families and with other professionals," "the initiation of systemwide education and consultation," "a sense of helping shape the system direction and commitment," and "the intellectual and pragmatic challenge."
Recommendations
In April 1993 the results of the evaluation were released to the system CEO and current and former members of the CEC. Based on the results, the report made nine recommendations.
Reflect on Growth
The review of the CEC evaluation suggested that the committee had moved beyond the development stage and entered a period of active growth. With CEC members having made great strides in educating themselves, the report suggested that the committee consider whether to broaden its focus by developing its knowledge base and skills for bioethical education and policy recommendations. It also suggested the CEC consider placing more emphasis on corporate and social ethics.
Continue Operations
The committee's growth and accomplishments are strong arguments for its continued functioning, the report noted. It concluded that the CEC can continue to provide the system and its members informed perspectives on ethical problems.
Consider New Ethical Mechanisms
The report raised the possibility that the CEC may want to reflect on suggestions that mechanisms be put in place to address ethical issues. Such mechanisms would have to be broad enough to confront the ethical dilemmas associated with such factors as increasing patient demands, scarce financial resources, and advanced technology.
Members would also need to become more knowledgeable about and sensitive to competing values in these areas, which would enable them to better educate the system and the IECs and to influence policy development.
The mechanisms the report suggested might be developed included:
- A credible core reference group for education and consultation
- Consultants
- System ethicists who collaborate with others to produce proposals and policies for CEC review or who direct ethics programs
Reassess Successful Initiatives The CEC's most notable accomplishments, which include a 1989 AIDS policy paper (with an educational component) and a 1990 paper titled "On an Understanding of Justice and Charity," may need to be reviewed, the authors of the report noted. As the AIDS pandemic worsens, the committee may wish to revise its policy and educational program. CEC members may also want to evaluate the "Justice and Charity" paper's usefulness to audiences outside the committee to determine whether it should be widely disseminated to spread its message.
Explore Cutting Edge Issues and New Paradigms
The evaluations indicated that the CEC devoted most of its attention to bioethical issues, but also moved into business ethics in its considerations of physician ventures and the allocation of scarce resources, the authors said. They saw involvement in the relatively unexplored area of corporate ethics as a sign of the committee's growth.
They suggested that the CEC's expertise in this area may enable some members to explore how models of analysis developed to address bioethical issues may be used in wrestling with questions of business ethics. By the same token, members' experience with established approaches to corporate ethics may give them added insight in approaching bioethical issues. An ethical framework that draws on all these areas can provide the system and its members with innovative perspectives on the ethical problems they face.
Integrate Standards for Community Benefit
The system and its members have an obligation to ensure that the needs of their respective communities are met, the report emphasized. The authors suggested that a challenge for the CEC would be to review how community benefit initiatives are integrated into strategic plans, community needs assessments, education programs, and other systemwide projects.
Establish Standards for Ethics Committee Orientation The authors noted that, in setting standards for the orientation of new ethics committee members, the CEC had worked to understand the difference and bridge the gap between abstract, "textbook" ethics and the day-to-day reality in sponsored institutions. The ideal outcome would be for all members of the system to be prepared to confront the dilemmas they inevitably face when attempting to translate abstract principles into concrete action.
Review Membership and Meeting Structure
The CEC's composition may need to change, the report's authors advised. They noted that the committee recognizes the importance of appointing members who address the system's identified ethical needs. As integrated delivery networks, joint ventures, and managed competition become more prominent, the CEC may need more members with experience in corporate and business matters.
The CEC may also need to schedule meetings based on the tasks its faces and how quickly they need to be accomplished. Typically, meetings are required more frequently in a committee's early stages, when members are establishing relationships and learning to grapple with difficult problems. As members gain experience and take charge of their roles and responsibilities, the committee may have to meet less often.
Propose an Ethical Framework to Translate Mission and Values into Action
In collaborating with others in ethical decision making, the CEC's leaders must help assign priorities to competing values such as free market enterprise versus charity care, competition versus collaboration, disease focus versus wellness focus, and science versus humanism, the authors suggested.
They said that the ethical foundation embodied in the SMHS vision and mission can provide a framework to ensure that the system's philosophy and values inform its actions. SMHS and its members are committed to developing a worldview that enables them to see patterns of organizational and system behavior; to grasp the root causes of illness, disease, and other health-related problems; and to understand why the poor and other disadvantaged groups suffer disproportionately. A mature CEC will become an advocate for a more just healthcare system by carrying that analysis outside the system and into communities, Congress, courtrooms, and corporate boardrooms.
Continue to Grow
According to the report, comments from members indicate that confronting contemporary ethical issues will require the committee to:
- Perform in-depth analyses of current healthcare issues
- Continue work on defined goals
- Assist in policy formation
- Help realize the SMHS Vision 2000, strategic plan, and articulated core values
- Educate current and new members
- Network, internally and externally
Current CEC Activities
The CEC has already reflected on its growth, renewed its commitment, and formed a task force to develop an ethical framework that can be used systemwide to translate the SMHS mission and values into just action. Although the evaluation of the system's CEC has some limitations, the results clearly demonstrate that the committee has achieved real growth. Committee members also believe that the process used to evaluate the CEC can be easily adapted for evaluating other ethics committees.
The Widening Scope of Healthcare Ethics
In the past decades a number of elements have combined to bring bioethical issues to the forefront of ethical debate and analysis and to prompt healthcare providers to create ethics committees. Factors such as the conflict over whether to withdraw life support for persons in persistent vegetative states such as Karen Quinlan, Nancy Cruzan, and Christine Busalacchi; the "Baby Doe" controversies (which arose in 1982, when a baby with Down's syndrome and esophageal atresia was allowed to die after a local court approved withholding food and water); patient and consumer rights' movements; and increased use of organ transplants have created a need for guidance in reaching consensus and articulating positions.
As these issues became more pressing, the federal government and other national organizations launched initiatives to clarify the ethical responsibilities of medical researchers and care givers. The 1993 standards of the Joint Commission on the Accreditation of Healthcare Organizations are only the latest example of such initiatives. Others include the 1974 National Commission for the Protection of Human Subjects and the guidelines issued in 1985 by the American College of Healthcare Executives for general ethical and bioethical issues and decisions.
More recently, cost-containment policies instituted by governments and healthcare organizations have created new ethical dilemmas for providers. In 1990 Cynthia B. Cohen, an associate of the Hastings Center, suggested that mature ethics committees would soon be moving outside the walls of their institutions into the halls of Congress, courtrooms, and corporate boardrooms to facilitate fair decision-making processes for resource allocation and the protection of individuals' freedom of choice ("Ethics Committees as Corporate and Public Policy Advocates," Hastings Center Report, September-October 1990, pp. 36-37). Similarly, a 1991 Catholic Health Association document, Corporate Ethics in Healthcare: Models and Processes, calls on providers to develop systematic methods of analyzing the ethical implications of corporate policies, practices, and strategic decisions.
Catholic providers are also examining their ethical responsibility to confront some of the root causes of poor health, such as poverty; inadequate housing, nutrition, and education; and violence. Ethicists are turning to Church teaching for guidance in realizing a vision of a just organization, community, nation, and world.
SMHS Corporate Ethics Committee
Education Devise strategies for education on ethical issues and ethical decision making for the corporate ethics committee, institutional ethics committees, chief executive officers, the system's board of directors, and local boards of trustees.
Articulation Articulate key components and principles of Judeo-Christian and Catholic ethics that are relevant to SMHS.
Decision Making Develop guidelines for ethical analysis and decision making.
Policy Development Develop broad-based policies to guide operations or policy development in individual facilities.
Program Development Establish guidelines for the development of ethics programs in component institutions.
Evaluation Conduct periodic evaluations of the comprehensive ethics program.