Overview and summary of Ethical Responsibilities of the Healthcare Executive

The Healthcare Executive’s responsibility to the profession of Healthcare management is define in five domains.  The first domain is to the profession of Healthcare Management.  Within this domain the executive is, among other considerations, expected to uphold the Code of Ethics and mission of the ACHE; conduct professional activities with honesty, integrity, respect, fairness and good faith; comply with all laws and regulations pertaining to healthcare management; and enhance the dignity and image of the healthcare management profession through positive public information programs.

The second domain of responsibilities for the healthcare executive is to patients or other served.  As with the previous domain, there are multiple considerations that include a responsibility to work to ensure the existence of a process to evaluate the quality of care or service rendered; avoid practicing or facilitating discrimination and institute safeguards to prevent discriminatory organizational practices; and work to ensure the existence of procedures that will safeguard the confidentiality and privacy of patients or others served.

The healthcare executive’s responsibility to the organization is the third domain.  Within the scope of his or her authority, the healthcare executive will provide healthcare services consistent with available resources, and when there are limited resources, work to ensure the existence of a resource allocation process that considers ethical ramifications; lead the organization in the use and improvement of standards of management and sound business practices; be truthful in all forms of professional and organizational communication, and avoid disseminating information that is false, misleading or deceptive.

The fourth domain of responsibility for the healthcare executive is to employees.  Within this domain are responsibilities such as creating a work environment that promotes ethical conduct by employees, and establish appropriate grievance and appeals mechanisms.

Community and societal responsibilities are the fifth domain for the healthcare executive.  As with the other domains, the healthcare executive will work to identify and meet the healthcare needs of the community; encourage and participate in public dialogue on healthcare; work to support access for all people to healthcare services.

Each domain has additional listed responsibilities.  Those responsibilities that I have chosen to identify are behaviors that I often see or hear about on a weekly if not daily basis.  However, it is also the responsibility of the healthcare executive to report violations of the code is reasonable grounds have been established.  The “reasonable grounds” criterion deserves more attention and is the scope of this overview.

There are two of the practice questions that ask essentially the same question, but give different answers. The first #6 asks "Which of the following is not a benefit of an ethical culture?" The answer given is "Improve Employee Morale" The second question, #15 asks"Which ofthe following is not a benefit a Healthcare Organization experiences when it fosters and demands an ethical environment?" The answer given here is "Improved Productivity" However, Improved employee morale is one of the choices.

According to the article, "Strengthtning Ethical Decision Making" by William Nelson, both answers are correct. In his article he specifies that increased Employee loyalty is a benefit of an ehtical culture, however, he doesnot mention employee productivity.  I believe, however, that increase employee morale wouldbe a result of an ehtical culture, which wouldleadto improved loyalty. Also, this improved morale and loyalty would haveto result in increased productivity. Therefor, there is really no correct answer for questions #6 and #15.

Do you agree?

Given the results described in Bill Nelson's presentation, I believe one could argue that establishing a proactive approach to ethical decision-making is, in and of itself, ethically sound.  Organizations with well-established, proactive practices seem to make higher quality decisions and have a more efficient process.  These "savings" would allow the organization to channel its resources and efforts to other matters that also affect performance.  With this, is it unethical to deal with systemic (or recurring issues) on a case by case basis?  It would seem that developing a proactive approach for issues that are more appropriately dealt with on a case by case basis, could be problematic as well.  In your experience, what practices allow the organization to establish the best balance.  If the cost of developing a policy or guideline exceeds the value that the organization will accrue by using it, does that imply that the proactive approach is not appropriate for the situation?  What other criterion should be applied when determining whether an issue should be dealt with proactively.  Any thoughts or comments would be greatly appreciated.

 

Which moral philosophy has a focus on what makes a “good person” rather than on what makes a “good action”?
a) Natural Law
b) Rawls
c) Casuistry and ethics of care
d) Virtue ethics

 

Which of the following is not one of the Ethical Principles?
a) Respect for persons
b) Justice
c) Professionalism
d) Beneficence

 

Factors to taken into consideration when addressing an ethical conflict include all of the following except:
a) The mission statement and values of the organization
b) The value-driven perspectives of key stakeholders
c) The most desired option, regardless of perceived practicality
d) A means of publicly disclosing the final decision, including the ethical reasoning

Should robots be programmed to make ethical decisions?

This question covers two areas:  governance and ethics.  In situations that fall under an organization's clinical and operational practices, yet have strong religious and/or ethical considerations (such as pregnancy termination or end of life care), what is the role of the board of directors?  Would be interested to hear thoughts, and if organizations are struggling with this balance.

The 1949 Geneva Conventions for the Amelioration for the Sick and Wounded on Land and the same convention for those on sea were designed to succor the wounded, non-combatants, and detained (i.e. medical, religious personnel) during warfare; a semblance of civility and restraint in nation-state warfare.  Today's environment of third-party, extra-nationals has strained the Geneva Convention accords to the breaking point, from interrogations to detention. 

In 2006, I was the task force surgeon for a classifed joint special operations task force battling terrorists in an undisclosed location off the Horn of Africa.  The ethical quandry we faced was what to do with the terrorists once we wounded/captured them.  As non-state actors, they did not have dedicated medical personnel with them nor did they have a medical evacuation system to utilize to get their wounded to safety; they were simply abandoned to us.  Primary triage and damage-control surgery (life-saving intervention) were not a problem - saving lives/limbs were fairly black-and-white: it's the ethically correct thing to do.  However, the question of long-term medical care became a very heated debate.  Who was responsible for their care and who would ultimately take responsibility for them?  The country of origin refused to take them back, stating they were criminals and that they did not belong to that society.  We could covertly drop them back into that country, but that would constitute abandonment of the patient and surely result in their death (as well as raise questions of illegally entering another sovereign country's territory).  We tried to find a third country within that region that would take the terrorists, but no country wanted to take them based on their criminal records and the social ramifications.  The vast majority of terrorists captured were of limited intelligence value and therefore did not qualify for long-term detention in a US facility.  There was absolutely no question of extraditing them to the US to stand trial for terrorist acts against US forces.  We were in international waters, so no national laws applied.  So what is the ethically correct answer regarding medical care?

What we ended up doing is holding them on US ships offshore, flying US surgical teams to the ships to perform surgery and post-operative care.  We provided the detainees with food, clothing, dental care, medical care, and jailed them in the ship's brig (jail) indefinitely while waiting for the US leadership to determine a final destination for the them (most likely paying a third party country to jail them once they were fully healed).

If that seems like common sense, let me thicken the moral plot by saying that the terrorists do not do the same in return.  They routinely kill their wounded prisoners because they are a burden and it strikes fear (and instant obedience) in their victims.  Healthy prisoners are, at best, ransomed or, at worst, gruesomely killed during propaganda videos.  As stated before, there is no nation-state to which these terrorists are beholden to; they are non-state actors and free to move about with impunity.  The authors of the Geneva Conventions did not forsee guerilla warfare scenarios on the scale that we see in today's asymmetric warfare environment.  While I certainly don't espouse a tit-for-tat policy of witholding care for enemy wounded, I believe that we - the United States - need to better define our roles and responsibilities, and LIMITS, when it comes to providing care for wounded, captured terrorists.   

With the rash of recent events (9/11, Katrina, Rita, H1N1, etc..) we have all been revisiting and revising our disaster preparedness plans. When it comes to being faced with ethical decisions, however, we seem to simply plan to have those decision made by the Ethics Committee. Unfortunately, this is where the planning stops, and the ethics committee is not necessarily planning for their disaster preparedness. The link  attached is for an article that outlines the ramifications of the decisions made at Memorial Medical Center in New Orleans during Katrina, and I believe makes apparent the need for Ethics Committees to proactively set policies and guidelines on the criteria for  how decisions will be made in crisis situations.

http://www.nytimes.com/2009/08/30/magazine/30doctors.html?pagewanted=1&_r=2

 

It is more imperative now than ever before for our facility to utilize our ethics committee to determine how we will utilize our resources wisely to cover our community in the event of a pandemic H1N1 episode.   Our concerns are whether there will be enough vaccine, anti-viral medications and bed space, along with respiratory care support to manage an event of this proportion.  We consider the 911 system will probably be overloaded in our community and that some more critical patients will be delayed in transport over transport of less critically ill Influenza like Illness patients.  These events will stress our committee, thus detailed planning is underway to evaluate what the conflict might look like, identifying those at risk, determining the ethical perspectives to this and developing options.  It is ironic that the pre-planning follows the eight steps listed in the required reading.

Among the many ethical issue examples throughout the readings, I think a major responsibility of a healthcare executive is to address and plan for the growing number of complex disasters that may occur in the organization and community.  One issue of ethical discussion in my organization surrounds the pending challenge of pandemic influenza in terms of allocation of scarce resources and health care workers’ duty to provide care.  I’m curious to hear what others’ experiences/discussions/plans are for dealing with this as well as how your ethics committee has been involved.

 

Health law and ethics are interrelated. Medical ethics - respect for autonomy, beneficence, non-maleficence, and justice – are principles used by various branches of government to formulate health laws and polices, which influence how health care is delivered and managed. These are forms of procedural jusctice. Anderson et al (2001) confirmed,

 

Central to the solution of ethical problems in health services is the role of law, which sets forth the legislative, regulatory, and judicial controls of society. The development of law in a particular field narrows the discretion of providers in making ethical judgments. At the same time, law sets guidelines for determining policy on specific issues or in individual cases. (Chapter 16, p. 3)

 

I believe the formulation of most health laws/policies occur at the federal level, while execution occurs at the state level. However, as with physician-assisted suicide (Oregon), stem cell research funding (California), and nonprofit healthcare mandates, it appears the state shoulders the primary influence in the way healthcare is carried out.

 

Autonomy

 

In health care, respecting people's autonomy has many prima facie (clear) implications. It requires us to consult people and obtain their agreement before we do things to them - hence the obligation to obtain informed consent from patients before we do things to try to help them. Medical confidentiality is another implication of respecting people's autonomy. Without such promises of confidentiality patients are also far less likely to divulge the often highly private and sensitive information that is needed for their optimal care; thus maintaining confidentiality not only respects patients' autonomy but also increases the likelihood of our being able to help them. (Gillon, 1994, ¶ 6)

 

Example

 

In the ICU/CVICU, I cared for a young woman who was a Jehovah Witness. She was having severe bleeding related to her period. She had lost a vast amount of blood over several months and she required blood transfusions to save her life. As a Jehovah Witness, she did not believe in receiving blood products. She signed her Medical Power of Attorney over to her pastor, because her husband wanted her to receive the blood transfusions to save her life. She ended up dying and left a husband and three small children behind. Her religious beliefs were upheld.

 

Muramoto (2001) concluded, “According to dissidents, ostracism and shunning by family and friends work as strong deterrents against leaving the religion or acting against the church’s teachings, thus compromising the freedom and autonomy of patients who are Jehovah’s Witnesses” (¶ 4). Internal dissidents criticize this practice because they feel it pressures those who have differing views on this issue and compromises independent decision-making in medical care.

 

In 2002, changes in the policy of refusal of blood by Jehovah’s Witnesses dictate that members can remain silent about the medical treatment they receive and avoid religious punishment. However, the church no longer views members that accept blood products as true Jehovah’s Witnesses. Therefore, it is essential for health care professionals to observe the integrity of medical confidentiality of Jehovah Witnesses. The Patients Bill of Rights concluded, “You have the right to be treated in a considerate and respectful manner which considers your privacy and your right to confidentiality” (University of Health Network, 2005, Your Rights section).

 

An adult, who is of sound mind, has the right to determine what shall be done with his/her own body. Doctors and nurses help their patients to exercise this right when they provide information about medical treatment that they are recommending. When patients agree to the recommended treatment, they have given informed consent. A patient also has the right to refuse the recommended treatment. For example, religious or cultural beliefs often go against treatment modalities. A Jehovah Witness refusing blood products is a good example of this. If a patient is not aware of these basic rights, autonomy is lost and the ability to decide one’s fate is jeopardized.

 

Other examples of autonomy issues in health care law/ethics include abortion, medical directives, right to die, HIPPA regulations etc...

Beneficence and Non-Maleficence

Whenever we try to help others we inevitably risk harming them; health care workers, who are committed to helping others, must therefore consider the principles of beneficence and non-maleficence together and aim at producing net benefit over harm. Nonetheless, we must keep the two principles separate for those circumstances in which we have or recognize no obligation of beneficence to others (as we still have an obligation not to harm them). Thus, the traditional Hippocratic moral obligation of medicine is to provide net medical benefit to patients with minimal harm - that is, beneficence with non-maleficence. To achieve these moral objectives health care workers are committed to a wide range of prima facie obligations. (Gillon, 1994, ¶ 9)

Justice

The fourth prima facie moral principle is justice. Justice is often regarded as being synonymous with fairness and can be summarized as the moral obligation to act based on fair adjudication between competing claims. In health care ethics, I have found it useful to subdivide obligations of justice into three categories: fair distribution of scarce resources (distributive justice), respect for people's rights (rights based justice), and respect for morally acceptable laws (legal justice). (Gillon, 1994, ¶ 13)

Examples of Beneficence, Non-Maleficence, Justice

Although laws and ethics each affects and is affected by the other, differences chiefly include the origins, purposes, and manner of enforcement of the standards. Laws are classified as either public or private (civil). Private (civil) laws have six classifications, but only tort and contract laws affect medical professionals. Public law can be divided into four categories, but the criminal classification is the one that most often affects the medical professional.

• Civil Law: Concerns relationships between individuals or between individuals and the government, which are not criminal. There is usually a monetary award or damage.
• Public Law (Criminal Law): These laws are made to protect the public from harmful acts of others. The purpose of criminal law is to define socially intolerable conduct that is punishable by law. A criminal act is one in which a person or institution commits an illegal act or a failure to act.
• Contract Law: Breach of contract refers to the failure, without legal excuse, to perform any promise or to carry out any of the terms of a contract.
• Tort: A tort is a wrongful act that is committed against another person or property that results in harm. A tort can be intentional or unintentional. (Fremgen, 2002)

 

Intentional Torts

 

• Assault: The threat of bodily harm to another. There does not have to be actual touching (battery) for an assault to take place.
• Battery: Actual bodily harm to another person without permission. This is also referred to as unlawful touching without consent.
• False imprisonment: A violation of personal liberty of another person through unlawful restraint.
• Defamation of character: Damage caused to a person’s reputation through a spoken or written word. 
•  Fraud: Deceitful Practice. (Fremgen, 2002)

 

Negligence is considered an unintentional tort and if a health care professional is not performing the recommended standard of care, patient injury can be the result. Fremgen (2002) stated, “The term standard of care means the professional must exercise the care that a “reasonable” person would use in a similar circumstance” (p.9).

 

Ethical codes are concerned with the morality of human conduct. Professional organizations such as the American Psychological Association, American Psychiatric Association, American Medical Association, American Nurses Association, among many others, declare their own “code of ethics” which help to guide and direct their ethical behavior. Some of these ethical guidelines include:

 

• Personal independence,
• self-reliance,
• kindness,
• helpfulness,
• generosity,
• confidentiality,
• faithfulness,
• justice,
• nonmaleficience (doing no harm),
• privacy, and
• truthfulness.

 

An Ethics Committee researches complaints alleging violations of the “code of ethics” for possible disciplinary action. They respond to inquiries involving ethical behavior and provide comments and recommendations on ethics-related rules proposed by national or state regulatory bodies.

Fremgen, B. (2002). Medical law and ethics. Upper Saddle River, NJ: Pearson.

 
Gillon, R. (1994, July 16). Medical ethics: four principles plus attention to scope [Electronic version]. BMJ, 309(184), ¶1-38.

 

Muramoto, O. (2001). Bioethical aspects of the recent changes in the policy of refusal of blood    by Jehovah's Witnesses. BMJ, 322(37), 39.

 

University of Health Network. (2005). Patient bill of rights and responsibilities. Retrieved September 14, 2009, from      http://www.uhn.ca/patient/patient_relations/rights_responsibilities.asp