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BY: DAVID T. OZAR, Ph.D.
Dr. Ozar is director, Center for Ethics and Social Justice, Loyola University Chicago.

Two important notions are crucial starting points for discussion of organizational ethics in health care organizations.

First, organizational ethics looks on organizations as actors, asking what organizations-as-actors ought to do and what they ought not do. But this practice — viewing an organization (a group of people) as a single, unitary actor — is significantly countercultural. It is almost a commonplace to say that our society's culture is highly individualistic, meaning that people in our culture tend to think chiefly about themselves and only secondarily about others. By "cultural individualism," however, I mean a tendency to think that only individuals act — to consider it mistaken to speak seriously of a group of people (such as an organization) as a single, unitary actor; speak seriously of organizations' obligations; or describe organizations or their actions as ethical or unethical.

But, in ordinary speech, much of our talk of action and of ethics is in fact about group actions and group actors. When, for example, you and a friend decide together to go to the movies and choose which movie to go to, there is good reason to say that the decision was made not by each of you singly, but by the two of you together, as a single actor. Many decisions made by family units, including many that have much more moral import than what movie to go to, have the same character. So, countercultural or not, the idea that groups decide and act as unitary actors is part of most people's ordinary lives. This idea is also fundamental for discussing organizational ethics in health care organizations.

Second, many service organizations, including many health care organizations, are led and managed by people of admirable virtue. But there is an unfortunate tendency in such organizations to forget how important organizational systems are to the organization's functioning, especially if the organizations are mission driven and their leaders and managers personally lead lives in accord with that mission and its spiritual sources.

What is at work here is what I call the "Myth of Enough Good People." If only there were enough good people making decisions in the organization, says the myth, then everything that happened in the organization and everything it did would be good as well. But the truth is that, if an organization's systems are not what they should be, then even good people may be hindered in doing their best — and may sometimes be led to do much worse than they could do.

So the perspective of the organization-as-actor is important not only because it is descriptively correct and philosophically important (the first crucial theme) but also because if in practice it is overlooked, bad things are more likely to happen, even in the best of situations, and the best things might well not happen.

In most health care organizations, especially in those guided by the Catholic tradition, these two points are understood — but, all too often, understood too abstractly. The task is to shape daily organizational practice to mirror the two points — a shaping that takes a great deal of effort, partly because it is countercultural and the Myth of Enough Good People has a great deal of power, and partly because it cannot be done without committing significant resources to it, resources difficult to draw from other good purposes for the sake of organizational ethics alone.

The Organization as Moral Actor
Even so, most Catholic health care organizations have taken steps to ensure that ethics issues are addressed.

Many have a leadership position that is focused on mission and core values and prepared to ask questions (and in many cases make major decisions) specifically from the perspective of what the organization, as an actor with a certain mission and certain core values, ought or ought not do. Most Catholic health care organizations also have educational programs (including orientation programs) for staff members concerning mission and core values. Most also have some sort of mechanism through which staff members can inform leaders about situations in the organization's daily life that do not mirror mission and core values as they should.

Researchers have conducted serious studies of organizational systems, looking for whatever it is that prevents good people from acting as they ought and trying to identify and enhance those systems that facilitate conduct in accord with organizational mission and core values. Some organizations have even instituted performance reviews on the basis of such information, so that assessment of individuals' and work units' practice of the organization's mission and core values is part of that process.

These ways of fostering organizational ethics are admirable, important first steps. But I will argue in this essay than an organization that goes no further than this is still not taking fully seriously what is implied when we affirm that our organization is a "moral actor."

A person does not make a moral decision and then act on that decision entirely by him- or herself. Many of our actions, including (from an ethical point of view) many of our most important actions, are not private actions involving ourselves alone; they are actions undertaken in the presence of — and very often directly engaging, involving, and benefiting — other people as well. To say the same thing another way, no one would consider a person morally admirable if that person's only concern was the improvement of his or her interior life. Even the most contemplative of saints interact with the rest of the world through their prayers.

In the same way, if we take seriously the idea that every Catholic health care organization is a moral actor needing to reflect carefully on what it ought and ought not do — and, moreover, an actor shaping its character not only internally but also in relation to other actors — then some additional questions need to be asked. We need to ask what sort of public actor and speaker the organization is, how its mission and core values shape its actions in the public arena, and whether its words fully support its mission and values.

Is It Safe to "Take a Stand?"
Unfortunately, many organizations (including many health care organizations), seem to work hard to not wear their missions and core values on their sleeves, so to speak. They seem to work hard to present themselves as neutral entities, standing for health and nothing else, in their public demeanor. "It is not our job to stand up in public for every value at work in this organization's daily life," such organizations appear to say. "The public expects us to stand for health, and that is what we stand for. The rest of our value commitments are our own business."

But no health care organization can possibly be that neutral in its real operational mission and values. Such a stance takes us back to the Myth of Enough Good People. If an individual were to say, "I don't need to stand up for my values in public — it is enough that I live by them internally and within myself; never mind what I do and say in public," few of us would consider him or her ethically admirable. By the same token, if "organizational ethics" does mean looking at organizations as capable of acting both ethically and unethically, then studied neutrality in an organization's public stance falls short of what we would expect of an ethically admirable actor.

Another likely response to the challenge offered here is the tendency to say, "We dare not do this alone." In the highly competitive health care market, an organization that does anything to stand out from the crowd, and does so in a way that may not be understood or appreciated by a significant fraction of the public, is taking a serious risk. The fear is well-founded. If the public does not understand or appreciate what an organization is doing, market competition is likely to crush it, even though its reasons may be admirable. And the public is unlikely to understand or be impressed by actions taken on the basis of an organization's conviction that, as an actor, it must make a moral stand. That is too abstract a concept to protect an organization from adverse market reactions.

Despite these concerns, mission-driven organizations must find a way to act fully in accordance with their values. In cases in which "taking a stand" threatens an organization's market position, one possible solution is joint action with other, similar organizations. Such a strategy not only offers some protection from market losses, because all involved are "in it together." It also offers the many other advantages of solidarity, ranging from emotional support and camaraderie to mutually shared resources, including the advantages gained from having many heads working together on shared goals.

Of course, collaborations among health care institutions might be construed as being in restraint of trade. But there are ways for organizations to collaborate that do not put them at significant risk of violating trade regulations. One method, for example, is to invite state or regional government, especially relevant health agencies, to be a partner in a collaborative project among hospitals or health systems. Not only is collaboration with public agencies wise from an antitrust point of view; it is also likely to broaden the perspectives of the hospitals or health systems. In addition, it will often smooth the path to change in matters of public policy and, by doing so, make genuine change more likely.

Of course, many Catholic health care institutions are already taking steps to act publicly in accord with their mission. Many provide significant amounts of charity care and already speak up in public forums in favor of health care reforms that will alleviate the plight of the underserved. Many Catholic institutions have also adopted socially responsible investment policies, acting either directly or indirectly (through carefully chosen investment managers) as stockholder-advocates, favoring corporate practices that are congruent with their organizations' core values and missions and opposing practices that are not. Their example should be considered seriously by any organization that, although viewing itself as an ethical actor, does not manage its investments in such reflective ways or respond energetically to unmet health care need.

Values and Advertising
But there are at least three other, subtler areas of organizational voice and action that 1) often go unnoticed; and 2), if intended to seriously portray the organization in question as an ethical actor, require much more action and a much clearer voice to be persuasive. These areas have to do with advertising.

Wonderful Outcomes
The first area concerns hospital or health care system advertising implying that all of the organization's outcomes are wonderful. Especially in America, there is a myth that no one dies and few suffer when receiving health care. Organizations whose advertising reinforces this myth may not, in fact, be speaking inconsistently — they may only be speaking profoundly naively.

But institutions adhering to the Catholic tradition should not be fostering this view of health care outcomes — not only because it is founded on a myth but also, and more importantly, because the Catholic Christian tradition believes that care for suffering or dying people is not simply or even primarily a matter of cure, if it works, or failed cure, if not. At a minimum, a Catholic institution must be committed to speaking openly and plainly in its advertising. But in affirming that good health care, under whatever auspices, always has a spiritual component, it must avoid advertising focused on "perfect" physical care.

To be sure, it will be challenging for Catholic organizations to find ways to "sell" contemporary Americans health care while acknowledging that, sooner or later, everyone suffers and dies. But working in this direction is surely consonant with the Catholic Christian tradition; and, at a minimum, it is inappropriate for Catholic health care advertising to suggest that all outcomes are wonderful.

Just Another Consumer Good
One of the most dangerous aspects of health care advertising in contemporary U.S. society is the extent to which it suggests that health care is just one more consumer good in the marketplace. The danger of this message is twofold.

First, it reinforces that increasingly common American assumption that all desires are equally important — and that anything called a "need" is no more than a strong desire. Taken seriously, as it is in some parts of our public life, this view undermines the conviction that health care (or at least some aspects of health care) belong to the category of basic needs; and the companion conviction that such needs have special priority over others because they have special moral significance. Unmet basic needs, this conviction holds, have special moral priority because they leave a human being unable to pursue meaningful goals effectively; unmet basic needs regularly undo humans' capacity for reflection and choice, not to mention happiness and joy.

Second, portraying health care as just another consumer good also undermines the conviction — traditional but increasingly challenged in contemporary American society — that good health care depends on the trained expertise of the health professions and of individual health professionals. If good health is no more than one of a multiplicity of desires, and if determining whether something fulfills a person's desire for health is simply a matter of his or her own judgment, requiring no meaningful input from others, then the role of expert judgment — and eventually the justification for having special institutions devoted to professional health care — is sharply challenged.

For both these reasons, a Catholic health care institution needs to examine its voice, in the advertising it creates, to see whether that advertising directly or indirectly suggests that health is just one of many possible consumer goods.

Technological Expertise Solves Everything
Much health care advertising suggests that good health care is essentially a matter of proper technology and its mastery by the organization's staff. Our society suffers in many ways from the conviction that health care technologies are flawless and that any outcome less than ideal must be the result of human incompetence in using the technology. Hospital and health system advertising often supports the belief that the chief difference between one hospital and another is in technological expertise. Many Catholic hospitals make some effort to suggest that there is more to health care than technology and its mastery. But the question remains, concerning even those organizations that emphasize the importance of spirituality and human relationships in health care, whether their advertising still suggests that what really makes people healthy is technology.

Finding an organizationally ethical voice in such matters as the three mentioned here — a voice consistent with mission and core values — is not such a stretch from current practice as to require the Catholic organization to begin speaking from scratch. Most Catholic health care organizations already speak, some of them loud and often, through their advertising. The Catholic organization's real challenge is to begin looking at its advertising through the lens of its values and mission and to ask if that advertising is not — subtly, but nevertheless pretty clearly — working at cross purposes with what the organization claims to stand for. There are probably other, similar areas in which the organization could begin examining itself, but the three just mentioned are good places to start.

As mentioned above, for an organization to think of changing its advertising — advertising that has been carefully designed with market share and audience bias and preference in mind — means risking market loss. And in today's highly competitive marketplace, that is a hard pill to swallow. Here again, however, collaborative action among hospitals and health systems seems a possibility. Such action might begin with a jointly supported study of the impact on the public, in terms of the three mission-adverse themes mentioned above, of hospital and health system advertising across a region. There might well be ways to involve public health agencies, many of which are dealing with the effects of such miseducation in the lives of those they serve. But the point is to start the thought process of matching speech and action to mission and values in public ways.

If an organization takes seriously its role as a potentially moral (or immoral) actor and speaker, as an entity that is therefore shaping its own moral character by its actions, then it must attend to its moral life in ways that go beyond its own walls. Such an organization must examine its public impact, not only in obvious, consciously designed, programmatic ways but also in its subtle interactions. Once such self-examination becomes habitual in the life of the organization, then it will be possible to think of our organizations, as we do of truly admirable individuals, as virtuous.

An earlier version of this essay was presented to the Fourth Biennial Loyola Conference on Organizational Ethics in Health Care, May 17-19, 2006, at Loyola University Chicago. I am grateful to conference participants and other colleagues who commented on that presentation.