Student: Stanley

Ethical Issues For Managers

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.

 

IDENTIFYING     ETHICAL          PROBLEMS

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.

Copyright © 2011. Health Professions Press, Inc.. All rights reserved.

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:

  • Is     there a         clearly        enunciated  value        system         reflected        in        the        organization’s        culture?
  • Is     there an       institutional        ethics committee   to        resolve         ethical        issues?
  • Is     this    patient         being        treated         as       I        would           wish   to        be?
  • Is     the     patient        protected    from        unnecessary           risk?
  • Does          the     consent        process        adequately        inform          the        patient         about the        treatment        contemplated?

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.

SOLVING   PROBLEMS

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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    Analyzing—separating          the     overall          structure      of          a         problem          in        a          particular     case          into    its major          components
  • Weighing—assessing          the     strengths          and    weaknesses          of       various          alternatives that          could be used          in        solving          the     problem          by       balancing          them  against          one    another
  • Justifying—providing          a         compelling          and    sufficient          moral reason          that    appeals          to       an established moral          principle,     such          as       “always          tell     the     truth”          [any   such          principle      must          be compatible          with   the          organization’s          philosophy  and          the     manager’s          personal      ethic]
  • Choosing—selecting          one    or       more          of       the          available          alternatives,          preferably   on          the     basis of          a         position          that    can     be          and    has     been          shown          to          be      justified
  • Evaluating—reexamining         the          choices         and          their          justifications,          identifying          unanswered questions,  and          relating          decisions      about          one    particular          case   to       similar          cases2

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.

 

DEVELOPING     A          PERSONAL          ETHIC

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:

  • Do   the     principles     apply        to       the     broadest        possible       range of        ethical          issues?
  • How useful and    applicable        are     they   in        solving         ethical        problems?
  • Do   they   use     the        scientific      method        in        terms of        exactness,        systemization,       and        predictability?
  • Are  the     ethical        concepts      clear  and        consistent?
  • Are  they   in        conflict        with   or       consistent        with   other knowledge        or       life        experiences?
  • Are  they   reasonably        adaptable    to       a        changing      world?

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.

 

CONCLUSION

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.

 

NOTES

  1. Paul            B.           Hofmann.     (1995,   November/December).     Performing         an          ethics     audit.    Healthcare     Executive            10(2),    p.     47.
  2. Frank          Harron, John     Burnside,            &            Tom     Beauchamp.       (1983).  Health     and        human  values   (p.     4).          New       Haven,  CT:     Yale University  Press.
  3. David         E.            Berry     &     John      W.          Seavey. (1984,     March/April).     Reiteration     of           problem     definition            in            health     services administration. Hospital     &            Health   Services     Administration  29(2),    p.     58.
  4. Ibid.,           p.            59.

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