From Chapter 2 and Figure 4 (Schema for solving ethical problems), describe some of the administrative/organizational challenges as it relates to ethics that managers must consider when looking to solve ethical problems.
Must be at least 250 words
Supported by at least two references
Darr, K. (2011). Ethics in health services management, fifth edition. Retrieved from https://ebookcentral.proquest.com
CHAPTER 2 RESOLVING ETHICAL ISSUES
anagers are problem solvers. It is the reason they are hired—organizations without M problems need no managers. Some problems burst on the scene. Something is clearly amiss when a wildcat strike occurs among the nursing staff or when a newspaper editorial attacks the organization. Other problems are hard to uncover and often provide no clear evidence or warning. They must be identified and treated early; undetected, they will grow and may threaten the organization’s survival. The aphorism “a stitch in time saves nine” is never truer. Solving them is similar to detection and early treatment of disease.
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Successful managers possess highly developed conceptual and problem identification skills. Preventing (if possible) or identifying and solving ethical problems with the least disruption to the organization are as critical as solving management problems affecting personnel or finances. Ethical problems have implications for traditional management areas, and traditional management problems have ethical dimensions. It is important to note in using this comparison that the techniques and skills employed in solving ethical problems have many similarities to those needed to solve management problems. Problem solving is a generic process applicable to both.
Often, managers believe that they are inadequately prepared to recognize ethical problems and even less able to solve them. This view understates the typical manager’s credentials and abilities. Identifying ethical issues that could become problems is primarily a matter of mindset, attitude, sensitivity, and application of common sense when reviewing or analyzing a situation. Identifying an ethical problem and its dimensions is often less difficult than developing and implementing morally acceptable alternative solutions. Developing and implementing solutions will likely require assistance from elsewhere in the organization or even from outside it.
Managers who see their function only as solving problems of staffing, directing, budgeting, controlling, organizing, coordinating, integrating, and planning are more in need of increased awareness of ethical issues than postgraduate education in philosophy. Methodologies similar to those used to solve traditional management problems can be used to solve ethical problems, whether they are administrative or biomedical. (This generic process is examined later in the chapter.) However, traditional management issues often overshadow and may even overwhelm the ethical dimensions that invariably accompany them. In addition, the ethical dimensions of managerial problems can be subtle, which complicates initially identifying and then solving them.
Managers use authority delegated by the governing body to represent the organization. As discussed in Chapter 3, the organization’s philosophy provides a general context for the manager’s activities and decision making. The presence of an organizational philosophy, however, does not eliminate the manager’s need for a personal ethic. A personal ethic provides a framework—a grounding—for decisions and permits greater refinement of principles, rules, and particular judgments (as well as actions or nonactions) than is likely using only the organization’s statement of philosophy. It bears repeating that each human being is a moral agent whose actions, nonactions, and misactions have moral consequences. Morally unacceptable conduct cannot be excused because someone was “following orders” or policy, regardless of their source. Orders from lawfully constituted authorities, such as courts, pose a special problem. Moral agents who consider such orders unjust or immoral may engage in civil disobedience, but in doing so, they must be prepared to bear societally imposed sanctions. The ethical (moral) implications of acts must be considered independently.
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Occasionally, there is conflict between the organization’s ethic, as expressed in its philosophy, and the manager’s personal ethic. The organization is a bureaucracy and the manager must carefully consider the implications of acquiescing to its values. This follows from the concept of moral agency. Often, it seems easier to “go along to get along” than to risk one’s position by speaking out. Professional dissent or whistle-blowing are rare, despite evidence that sharp or dishonest practices, criminal behavior, or activities that pose a danger to the public are not uncommon in organizations, even those in the health services field. Managers must recognize both the distinction between and the integration of an organizational and a personal ethic. They must not perform their daily tasks with little thought to the ethical context or implications of what they do, fail to do, or do badly.
In terms of the problem-solving methodology described below, the organization’s philosophy and the individual’s personal ethic are vital. They provide the framework and context in which the manager functions, and they enhance sensitization to and identification and solution of ethical problems so that managers can approach these problems as they would those of traditional management.
Another technique that may be useful in identifying ethical problems is the ethics audit. Conducted much like a financial audit, an ethics audit uses a set of criteria to compare actual with desired performance. Small increases in some measures should alert managers to actual or potential ethical problems: patient complaints, incident reports, and legal actions; employee grievances, resignations, terminations, and wrongful discharge complaints; medical staff complaints and resignations; problems with suppliers and other vendors; and adverse publicity. The ethics audit has three steps. First, analyze key documents (e.g., mission, vision, and values statements) and their operationalization in policies and procedures, with special attention paid to issues such as uncompensated care, confidentiality, consent, conflicts of interest, and sexual harassment. Second, survey representative board members, managers, physicians, employees, volunteers, and community residents and organizations to determine whether actual performance matches that desired. Third, address deficiencies through education or other appropriate strategies.1 Compliance or noncompliance with laws and regulations raises other ethical (and legal) issues.
Administrative Ethical Issues
Leadership is essential in management. It includes setting goals, establishing direction, and guiding the organization. These tasks are more ethics-sensitive than are many routine managerial activities. Day-to-day activities (i.e., transactional leadership) seem less tied to values, but even these are based on earlier decisions rooted in ethical principles, whether or not those principles are identified and expressly stated. However management functions are interpreted, human beings cannot escape their role as moral agents. Managers set a tone and establish a context for the organization and staff. They can neither avoid scrutiny of their personal ethic nor ignore its congruence with the organization’s philosophy.
Managers hold positions of trust, which may not be used for personal advantage or personal aggrandizement. These are essential elements of a personal ethic if one seeks to be an effective leader. Managers must not act in any ways that raise the slightest hint of wrongdoing. Actions (and nonactions and misactions) should be judged by applying the ethical principles and virtues discussed in Chapter 1. Another effective way to clarify the pragmatic effect of an action is to step back, as though one were an outsider, and view what is being done or contemplated. One should ask, “How would the public and my colleagues see this decision?” This “as seen through the eyes of others,” or “in the light of public scrutiny,” standard for judging managerial decisions is helpful. A cynic’s standard is not useful—meeting it is impossible because cynics see problems when it is unreasonable to do so. Skepticism is a useful criterion for managers to apply as they seek to understand how their actions might be interpreted. A standard of discovery is unacceptable because the concept of “if you don’t get caught, it’s okay” negates the need for ethics and substitutes deviousness and deceit.
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In a way quite different from a personal ethic or an organization’s philosophy, the law is a baseline of what is considered ethical. The Introduction noted that laws provide useful comparisons; however, they guide us only partially because the law is a minimum standard of conduct, and no manager is effective by meeting minimum requirements. The manager qua leader must set an example that substantially surpasses what is expected of others. Professional codes also guide conduct and provide frames of reference. These codes have a more demanding level of performance than the law; however, they should be seen only as partially incorporating expectations of ethical performance.
Is it persuasive to argue that where one stands on administrative ethics depends on where one sits? Does the concept of “rank hath its privileges” apply to managing health services? Many senior managers act as though it does. One readily finds situations in which subordinates are reprimanded for behavior unpunished at the upper echelons. Here, it is “do as I say, not as I do” or “what is sauce for the goose is not sauce for the gander.” Few will fail to distinguish words from actions. This double standard sends staff a clear message of cynicism and inconsistency and greatly diminishes the manager’s ability to lead; respect is lost.
Managers can become sensitive to administrative ethical issues in several ways. They should be voracious readers of the popular press and professional literature because what happens elsewhere could become a problem for them. Codes of ethics are valuable guides to understanding the concerns of the profession and the parameters of acceptable action. Asking whether the Golden Rule is being met also helps identify ethical problems. Not to be forgotten is intuition and hunch, which form that sixth sense that something is wrong. Both can be nurtured to alert managers to the presence of ethical problems.
Identifying ethical problems means focusing on the principles of respect for persons, beneficence, nonmaleficence, and justice, as complemented by the virtues. One must ask if the actions contemplated violate them and then determine whether the violation is justified by special circumstances. A questioning mind permits managers to consider the situation further or seek assistance, as appropriate. Identifying administrative ethical problems requires attention to detail and constant vigilance.
Biomedical Ethical Issues
All contemplated and actual interactions with patients present potential sources of ethical problems, which range from paternalism to consent and from truth telling to decisions at the end of life. Managers may feel uncomfortable and out of place working to solve biomedical ethical problems. They should not. Medicine and the clinician provide key information that assists in making informed ethical decisions, but the decision itself is ethical (moral), not clinical. The distinction between clinical and ethical aspects of biomedical decision making is critical and is one managers must not forget. Managers will gain confidence with greater experience and exposure to biomedical ethical issues. Their participation is needed because increased medical staff–administration interaction results in a more effective and efficient organization, and because all biomedical problems have administrative dimensions. Thus, the manager’s involvement is critical.
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Managers do not supersede clinicians but are important to preventing or solving a wide range of biomedical ethical problems through actions, including serving on institutional ethics committees and institutional review boards and participating in resource allocation decisions. In addition, managers are key in developing the processes and operationalizing the policies, procedures, and rules that implement the organization’s philosophy.
As noted in the section on administrative ethics issues, managers need not take postgraduate courses in philosophy or ethics to identify the presence of potential problems, although such courses might be helpful. Primarily, identifying potential ethical problems requires sensitization, an inquiring mind, and a reasonably well-developed personal ethic. Questions such as the following help identify biomedical ethical problems:
As in any problem solving, asking the right questions may be the most important part of the process.
A key role for managers is stimulating the medical staff and other caregivers to develop the expertise to prevent or effectively address biomedical ethical problems. To do so, caregivers must be availed of procedures and rules to follow. Here, the manager’s role as a catalyst is much the same as that played in traditional administrative activities. Regrettably, codes of administrative ethics provide limited guidance in addressing biomedical ethical issues.
Unresolved ethical problems exact the same destructive effect on an organization as do problems involving personnel, finance, or the medical staff. Therefore, it is imperative that managers use a methodology for solving them. This poses difficulties, however, because few managers are formally trained in ethics. Ethical issues may seem more subtle than management problems, and because managers tend to be pragmatic, they are less inclined to grapple with nuances. Sometimes ethical problems are combined with and overshadowed by administrative issues. Furthermore, managers may consider ethical issues less important than other problems, perhaps because they do not comprehend their potentially devastating effect. These obstacles are surmountable, however.
In 1910, the American educator and philosopher John Dewey wrote in How We Think that problem solving comprises three stages: identifying the problem, identifying the alternatives, and determining which alternative is best. Implicitly or explicitly, successful managers use a similar process. The stages of the process include identifying the problem in terms of both the current manifestation (which may be only a symptom) and the underlying cause; developing alternative solutions and the decision criteria to judge them acceptable, unacceptable, or optimal; preparing an implementation plan for the solution selected; and developing a means to evaluate the solution, once implemented.
Philosophers use a similar methodology, moral reasoning, to analyze ethical problems. Its components are surprisingly similar to the manager’s problem-solving methodology:
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Problem solving is rooted in two broad models, the rational and the heuristic. Defining the problem is addressed differently by each. The rational model (sometimes identified with programmed decisions) assumes that one is faced with a specific problem and focuses primarily on a search for the optimal solution. Operations research, for example, is primarily a quantitative expression of the rational model to a wide range of management issues. In the hospital, it includes problems such as work scheduling—for example, developing a computer program that maximizes the preferred work schedule of a large number of nurses, or a program evaluation and review technique (PERT) chart used to schedule construction of a new building. These and similar techniques help an organization establish effective patterns for problem solving.
The heuristic model (sometimes identified with nonprogrammed decisions, or a learning model) acknowledges that some problems may be more diffusely defined, poorly structured, and are often not routine. It uses an iterative process of dealing with problem definition, as well as solution. Heuristic general problem-solving techniques have been suggested for training administrators. Heuristic problem-solving approaches that are quantitative and computer-based have been advocated.3
The distinctions between the rational and heuristic models suggest that solving ethical problems is heuristic. First, however, process and substance components must be separated, and ethical problems that recur and have similar features must be distinguished from those that are unique and unlikely to recur. Process components are more amenable to analysis and solution by the rational model than are substance (content/issue) components. Ethical problems that recur and have similar features are also more amenable to using the rational model. Even here, however, implementing the process may uncover unique or subtle problems of substance, such as the relative authority of different individuals in the decision-making process. The two problem-solving theories are not mutually exclusive, and the heuristic model often benefits from using a rational model for some analysis. Thus, problem solvers should never exclude either model.
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Graduate programs in health services administration and business administration teach the process of problem solving. Such methodologies are useful in solving ethical problems and are similar to the generic problem-solving model in Figure 4. The model is shown in two dimensions but should be conceptualized with time as the third dimension. In this respect, the model is like a corkscrew: While the process cycles from problem analysis to evaluation of results, the whole activity is moving through time.
In Figure 4, problem analysis begins when the manager objectively or intuitively finds something amiss. This occurs when actual results deviate from desired or expected results or a situation occurs that demands an organizational response. Examples of developments requiring management’s attention include a rapid decrease or increase in outpatient admissions, increased turnover among staff in a department, more uneaten food returned from patient rooms or the cafeteria to dietary, or an announcement that competing emergicenters are opening or closing. Some of these potential problems are foreseen through analysis of routinely collected data; others are apparent only after they occur. Obvious and defined problems will be more amenable to the rational than the heuristic model.
Similarly, the ethical dimensions of some situations are apparent. If a patient is diagnosed as being in a persistent vegetative state (PVS), an ethical problem having both clinical and administrative dimensions exists. An ethical problem is also present when the organization lacks an effective consent process. In such situations, heuristic problem solving is not the most effective methodology.
A potential administrative and biomedical ethics problem needs a solution only when the problem solver determines that it must be solved. Sometimes, before an ethical problem can be resolved, it ends (e.g., the patient in PVS cannot be resuscitated after cardiac arrest). The problem is gone, but it has not been solved.
Figure 4. Schema for solving ethical problems. (From Longest, B.B., Jr., & Darr, K. [2008]. Managing health services organizations and systems [5th ed., p. 279]. Baltimore: Health Professions Press; adapted by permission.)
Berry and Seavey4 argued that problem definitions “are fundamentally subjective [and] . . . are not objective, concrete realities; they are perceptions of reality.” This statement is correct as it bears on perceptions of cause and effect but must be qualified when applied to other situations. For example, several unexplained deaths in a nursing facility are a fact and will be defined by a manager as a problem that needs solving. Perceptions (subjectivity) vary in determining the cause or in identifying the underlying situation (problem) that may be the cause. Views of problems and their solutions are affected by the positions held and responsibilities of the individuals involved. Nursing service will likely provide a different explanation of the deaths than will management.
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Context is more important in solving problems that are primarily ethical than when solving management problems with few ethical dimensions. The context of ethical problems is the organization’s philosophy and mission interpreted and applied by a manager who is a moral agent with a personal ethic. Once an ethical problem has been recognized and defined as a problem needing a solution, it must be understood. The information about its extent and character may be available in existing data, or special efforts may be required to obtain it. Managers solving ethical problems will experience data deficits similar to those they confront when solving other problems.
Rectangle 2 in Figure 4 asks managers to identify three types of assumptions: those about the context of the problem, those about themselves, and those about the problem itself. The Baby Boy Doe case undoubtedly affected staff, and it is reasonable to assume that in similar cases, staff will become depressed and angry and morale will decline. One may also assume that a few staff members will be so upset that they will resign, turn to a union, or refuse to work in the nursery. Assumptions such as these require judgment by managers and may result in a decision to ignore the situation (i.e., not define it as a problem requiring a solution), which is what occurred in the case of Baby Boy Doe. The hospital accepted the parents’ directives and determined there was either no problem that required a solution or that the solution was to do nothing. Such a result is dependent on the organization’s philosophy and the individual manager’s personal ethic. Choosing to do nothing may be a solution, but only if it solves the problem as stated and meets the decision criteria better than other alternatives. Doing nothing must never be unchosen or occur by negligence.
Preliminary review of options occurs in Rectangle 3, in which tentative alternative solutions are identified and assessed. Here, decision makers may brainstorm creative solutions. Managers solving administrative or biomedical ethical problems must be mindful of the organization’s philosophy as well as their own personal ethic. Unless the constraints of the context can be changed, solutions falling outside them must be discarded. Arbitrarily ignoring or applying these constraints creates inconsistencies and discontinuities that eventually cause serious problems for the organization and the manager. Other, more general criteria are also applied in such instances.
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Alternative solutions that pass this preliminary screening are subject to detailed assessment. This assessment compares each option against specific decision criteria. Examples of these criteria are shown in Rectangle 4 of Figure 4: time available to solve the problem, real costs of all kinds (e.g., political, financial, reputation), opportunity costs, feasibility of implementation, adequacy of solving the problem, and benefits derived. Applying more specific criteria results in better solutions and outcomes. A primary benefit of greater specificity in the process is that managers must review, analyze, and be as precise as possible, both in defining the problem and in selecting the alternative that best solves it. This exercise is useful because it hones management decision making. A more sophisticated approach is to weight or assign relative values to decision criteria, since some are more important than others.
Before and after selecting an alternative, the manager must consider implementation and evaluation. A common failing is that great effort is put into developing a solution and beginning implementation. Then, managers are distracted by other problems. The result is that the solution flounders before it is fully implemented. Implementing the solution should receive as much attention as selecting it. Evaluation must be included in the solution so that difficulties can be identified and timely corrective action taken. Corrective actions are a subset of the problem-solving process and may involve the same or similar steps.
This ethical problem-solving methodology is useful for decision making by one manager, by a group of managers, by governing body committees, or by special-function committees, such as institutional ethics committees, institutional review boards, or infant care review committees. It is effective for solving one problem, considering guidelines for a class of problems, or developing a process to bring a similar methodology to bear on solving individual problems or groups of problems. Regardless of the source of decision making, once the process is established and policies (which have gone through a similar problem-solving process) have been formulated and implemented, operating procedures and rules will be established. This means that an issue such as consent has been considered and that the ethically acceptable policies, procedures, and processes have been identified and implemented. The desired result is that many ethical problems will be prevented. Exceptions and special attention will be necessary when the facts differ sufficiently from the assumptions implicit in the policy and procedures derived from it.
In this regard, it is unnecessary to distinguish administrative from biomedical ethical problems. Because both types will occur, policies should be adopted prospectively. Procedures and rules derived from the policies will address the majority of predictable, recurring ethics problems. That is why, for example, a governing body adopts a conflict of interest policy applicable to itself and management. Despite the usefulness of policies and procedures, problems occur in interpreting and applying them and unique ethical issues arise. It bears repeating that the problem-solving model discussed previously is usable on two levels: general policy development and consideration of specific situations or cases.
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In most ways, implementing solutions to administrative or biomedical ethical problems is the same as for management problems, though some distinctions are noteworthy. One is that ethical issues are often emotional. Examples are evidence that a manager has acted unethically (administrative ethics), or that a patient’s view of life and death has been violated or challenged (biomedical ethics). Thus, managers and staff who work to solve ethical problems must exercise greater sensitivity to human factors and must understand that they are not dealing with units of production or ordinary services. Another distinction is that administrative and biomedical ethical issues may have the potential for legal consequences. Although all health services organizations should apply a standard that is much higher than the minimum set by the law, mistakes do occur, and occasionally, there are problems that bring in lawyers. Yet another distinction is that negative public relations consequences may occur inside and outside the organization.
Health services managers begin their careers as adults who have an implicit personal ethic. In developing that ethic, managers have been affected by numerous influences beyond their own introspection, including family and friends, religious principles and teachings, secular education, and the law. It is in this context that adults become managers and that a personal ethic about management emerges. Some managers’ personal ethic may be only an intuitive sense of right and wrong, with no identifiable source or explicitly defined code of conduct.
Developing a personal ethic necessitates introspection and self-examination. Questions such as the following are helpful: “Who am I?,” “How do I view certain actions or activities?,” “What do I consider unethical?,” and “What is morally right or wrong?” Understanding and grappling with questions such as these are critical as managers search for the “right” answer to ethical problems. Both nascent and experienced health services managers use numerous sources to develop and refine their personal ethic. Chief among them are professional codes of ethics; organization values and culture; educational socialization; and the association and pressure of peers, subordinates, and superiors.
In selecting the principles to be included in a personal ethic, managers should apply the criteria of comprehensiveness, consistency, and coherence and ask themselves the following questions:
Although the criteria of comprehensiveness, consistency, and coherence are not applied with the rigor employed by a moral philosopher, they should be used when developing, judging, or reconsidering a personal ethic and when analyzing the ethics of others or disputing their reasoning or conclusions. In developing and reconsidering one’s personal ethic, it is useful to paraphrase Plato, who said that the unexamined life is not worth living.
The moral philosophy of casuistry has special relevance in the manager’s efforts to hone a personal ethic. Casuistry’s emphasis on cases and the reiterative nature of cases and similar events provide special assistance in terms of a personal ethic. Virtue ethics has a unique role here too. The virtues noted in Chapter 1 should be included in a personal ethic, and reexamining whether one is a virtuous manager will reinforce or highlight a need for further attention.
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In addition to the manager’s personal ethic, the organization’s philosophy is vital to ethical decision making. It is tempting to say that the personal ethic is and ought to remain the most important factor. However, one cannot ignore the realities of bureaucratic life. Some sectarian health services organizations seek complete congruence between a manager’s personal ethic and the organization’s ethic by hiring no one above mid-level management who is not an adherent to that faith. The wisdom of such a policy is examined in later chapters. Suffice to say that in modern, complex health services organizations, a significant and undesirable potential for discontinuity exists between the philosophy of the organization and that of its managers. However, the extent to which these philosophies must be identical, or even congruent, is unclear. It is likely that the organization’s philosophy and the values expressed in its culture will have a greater effect on development of the personal ethic of a younger, less experienced manager. Like everyone, managers can become set in their ways.
In solving problems, successful managers implicitly or explicitly use a methodology similar to that outlined in Figure 4. Effectively solving ethical problems requires the same attention and a similar approach. Managers cannot ignore ethical problems, and they must be prepared to participate in solving them. It is critical, however, to separate the technical and clinical dimensions from the ethical. This does not mean that health services managers supersede physicians or other clinical staff when biomedical ethics are present. It does mean that in an effort to operationalize the principles and virtues discussed in Chapter 1, managers must participate effectively in solving all types of ethical problems. It is the nature of the job that managers serve as team leaders and catalysts. Serving as the organization’s conscience is consistent with the manager’s role as moral agent in a position of ethical leadership. In terms of administrative ethics, the manager’s role is preeminent, but not to the exclusion of physicians.
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Successful managers have a well-developed personal ethic and a clear perspective on administrative and biomedical ethical issues. This ethic has been defined by drawing from a wide variety of sources. A personal ethic cannot be chiseled in stone; it will evolve over time. Although one’s basic view of the world is likely to remain relatively stable, experience, maturation, and technological developments will affect one’s personal ethic.