HEC Forum (2006) 18 (4): 342-348. DOI 10.1007/s10730-006-9024-z
© Springer 2006
Is Organizational Ethics the Remedy for Failure to Thrive? Toward an Understanding of Mission Leadership
Patrick McCruden · Mark Kuczewski
Consider three scenarios: 1. St. Kevin’s hospital had discontinued outpatient chemotherapy services several years earlier when the majority of this business moved to physician offices. Favorable Medicare reimbursement made this a profitable sector for oncologists and several opened or expanded infusion centers in their office practices. Recent changes in the Medicare program regarding reimbursement for chemotherapy and other oncology drugs has now led to physicians losing money on these same services. The local oncologists are now sending patients to St. Kevin’s to receive these needed services. However, this service is unprofitable for the hospital as well. Hospital pharmacy costs are increasing and the outpatient department would need to add and train additional staff to provide this service. Some in hospital administration feel the hospital should simply not offer this money-losing service; others believe the hospital has an obligation to cancer patients to provide the service since it is needed in the community. Dr. Jones, an oncologist and member of the St. Kevin’s ethics committee brings up the question during a regular ethics committee meeting. He asks: “Do you know administration is considering ending outpatient chemotherapy service?” He states emphatically that “the hospital ethics committee should be involved in these deliberations.” 2. Like every other business, Midwest County Regional Health Center finds that its healthcare costs are rising at an exponential rate. A twenty percent rate hike for employees is necessary to meet additional insurance costs. A concern is raised that this will make health insurance too expensive for entry level employees in the housekeeping and dietary departments leading to them dropping the insurance with the predictable decrease in their health status. A suggestion is offered that a sliding scale be put into place _____________________________________________________________________________________ Patrick J. McCruden, Vice President, Mission and Ethics, St. Joseph’s Mercy Health Center, P.O. Box 29001, Hot Springs, AR 71903; email:
[email protected]. Mark G. Kuczewski, Ph.D., Neiswanger Institute for Bioethics & Health Policy, Stritch School of Medicine, Loyola University Chicago, 2160 S. First Ave., Bldg 120, Room 280, Maywood, IL 60153; email:
[email protected].
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with higher paid employees absorbing a larger cost increase so that lower paid employees can pay a reduced premium. The Director of Human Resources is concerned that this will be perceived negatively by health professionals and supervisory personnel with higher salaries and may make recruitment for these positions more difficult. The suggestion is made that since this is ultimately a question of justice, that the issue be referred to the hospital’s ethics committee for resolution. 3. St. Luke’s hospital finds itself in an aging building located close to the downtown area. Site of the original hospital built in the early part of the last century, several additions have been added, the latest in the mid 1970s when a new patient tower was added. At that time it was state of the art but now it is badly run down, with semi-private rooms and aging equipment. The hospital has a busy emergency room and outpatient department buts its payer mix is very poor serving a growing number of the uninsured and Medicaid population. A new hospital needs to be constructed but there is disagreement as to where to build. Several voices advocate a new site in the western suburbs where the middle class population is burgeoning. Although there is considerable competition in that area, this better paying population will allow the hospital to expand into profitable service lines while decreasing its burden of charity care. Others are concerned that building in the suburbs will remove the last remaining hospital in the downtown area and have a devastating impact on the low-income population that the hospital serves. The question is asked: “Isn’t this the kind of question the ethics committee can help with?” Since the New Jersey Supreme Court Decision regarding Karen Quinlan more than 30 years ago advocated the use of multidisciplinary committees to address dilemmas in end-of-life care, health-care ethics committees (HECs) have become fixtures at many hospitals and health systems. Their place in the hospital organizational chart was reinforced when the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) began requiring that hospitals have policies and procedure to address ethical issues more than twenty years ago (JCAHO, 2006, Intent of RI.1). This standard did not mandate ethics committees, but an ethics committee became a typical method for achieving compliance in these standards. Even if the ethics committee was generally inactive, they would rekindle their activity for the tri-annual JCAHO review. At their inception and during their youth, most ethics committees found valuable and challenging work to address. The three-fold tasks of the ethics committee in education, policy development and consultation (Ross et al., 1986, p. 49) provided ample work for fledgling committees. Consensus in end-of-life care was still developing and so consultations were frequent. To
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decrease the need for consultations and to ensure consistency, policies needed to be developed to ensure that there were generally uniform approaches to DNR, organ donation, withdrawal of life support, palliative care, pain control, etc., within the institution. Ongoing education efforts were needed to train medical and hospital staff in the rapidly changing legal and ethical landscape of clinical bioethics. However, many committees “fail to thrive” (Kuczewski, 1999). While there was initial enthusiasm among members, many ethics committees have and continue to struggle with their purpose and meaning. This failure to thrive syndrome is characterized by a lack of clinical relevance with many hospital staff not knowing of the existence of the committee or how to contact it, meeting attendance dwindling, and a lack of clarity as to what tasks the committee should be undertaking. The conclusion that seemed to follow was that committees could revitalize themselves by refocusing on their educational missions. We believe that this is still correct. However, it is becoming more common to hear it said that ethics committees should “move beyond” their educational and consultative function (Ross et al., 1993, p. 11). Many ethics committees find themselves either looking for or being called to consider other issues such as the scenarios outlined in the beginning of this article under the heading of organizational ethics. This movement probably has several impetuses. Ethics consultations at many institutions continue to focus on common end-of-life issues. This may lead to a fatigue that can help contribute to failure to thrive syndrome. Furthermore, as the influence of business concerns has become obvious, a committee can easily feel that they are not dealing with the important ethical issues unless they are considering questions of the relationship of margin and mission. Should Ethics Committees be in the Organizational Ethics Business? At first glance this may appear to be entirely appropriate. It would seem an institutional ethics committee should be concerned with the ethics of the institution, which extends beyond clinical ethics issues. Even if an ethics committee decided to restrict itself to issues that impacted patient care, these can include questions such as the nurse staffing levels on a unit where poor inter-professional communication led to an ethics consultation, and billing and collection practices, as well as where to construct a new hospital can come up in the context of the mistrust of persons of color toward the hospital when end-of-life decisions are a issue (Andre, 2002, pp. 217-220). Similarly, disposition difficulties are often involved in ethics consultations and can suggest the question of service line development or restriction.
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Although this expansion of interest and influence might appear prima facie reasonable, we would suggest that ethics committees should restrict these activities for several reasons. First, most HECs lack the expertise to deal with these issues effectively. What little data is available suggests that most committee members are there because of interest rather than formal training in ethics (Fox et al., forthcoming). It is even less clear what business acumen is represented on a typical HEC. Second, HECs are likely to lack the stature and credibility necessary to address extremely sensitive issues such as those we raised at the outset. The rhetorical force of the word “ethics” may have some currency but must be predicated on expertise and a record of administrative fairness and balance in dealing with similar issues. We do believe that an ethics committee may have some contributions to make. But, we wish to suggest an alternative approach, an approach that centers on a “mission leader.” The Role of the Mission Leader and Organizational Ethics The role of Mission leader has existed for the last two decades in Roman Catholic healthcare facilities and is also prominent in many other faithbased, healthcare institutions. The Mission leader is an executive level position whose primary task is being attentive to the “mission” of the organization. This executive sits at the table with other administrative leaders and is tasked with ensuring that the mission and values of the organization continue to be integrated into the organization’s decisions. The development of the “mission leader” in Catholic healthcare grew out of the changes in healthcare and the changes in the Catholic religious orders that sponsored many hospitals and health systems (Grant, 1999). The initial impetus for many orders of religious women and men to enter the healthcare ministry was to care for the sick in imitation of Jesus Christ. At the time these religious sisters and brothers began these activities, healthcare looked nothing like the business of today (Nelson, 2001). Hospitals were fearsome places, for those whose families could not care for them at home. The remedies of medicine were few, and in fact often did more harm than good. Care giving in its most basic form: the kind word, the gentle touch, the cool drink were often all that could be offered to the sick. It was this ministry that drew religious orders of women and men to care for the sick, build hospitals, and eventually expand healthcare systems to provide care to the “least of these.” As the decades progressed healthcare became big business with hospitals and health systems becoming powerful business influences in their communities and in the nation as a whole. Religious sisters and brothers changed with the healthcare enterprise and learned the language of business
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alongside the language of theology. In the 1970s most Catholic religious orders suffered a large decrease in the number of vocations. Whereas in past years it was certain that the chief administrator of the hospital would be a member of the sponsoring community, there was now a lack of qualified sisters and brothers to serve in that capacity or in other leadership positions in the health system. Lay administrators were brought in to fill the void. With lay leaders having an increased role in the leadership of the organization, the obvious question became whether future organizational direction would be commensurate with the values and ethics of the founders or would Catholic healthcare look exactly like other healthcare enterprises save for the name on the door and the cross on the roof. From this concern the role of the “mission leader” was born. It was believed that the mission leader serving in an executive function would help ensure that the organizational values of the sponsoring communities would continue to influence the decisions, polices and practices of the organization. This position is usually chartered at a senior administrative level such as that of vice president and has a seat at those tables at which decisions affecting the direction of the hospital or health system are considered. This person’s perspective should reflect the mission for which the sponsoring order created the institution as well as the values of the religious tradition of the institution. Of course, this should not be a static perspective, but a perspective that adapts to the changing healthcare environment and seeks to balance the mission and margin just as the sponsoring orders did when they were the chief executives. The role should not be viewed as a lone voice “crying in the wilderness.” Just as the hospital Chief Financial Officer is not the only person concerned with finances, but who ultimately assures that the organization is addressing financial issues at every level of the organization, so too the Mission executive is not the only person concerned with organizational ethics and values, but rather is charged to ensure that these values are integrated into every aspect of organizational life, policy and practice. In general, the Mission leader will also create educational programming and reflective opportunities for all senior leadership members so that they may also become versed in the mission and tradition of the orders and institution. Why is the mission executive a better option than an institutional ethics committee for addressing the organizational ethics issues we have identified? We noted that the ethics committee as essentially lacking in expertise and authority. We believe that a qualified mission executive will possess both prerequisites. Although few mission leaders are expert in all the areas necessary for such important decisions, they are able to call upon these
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resources throughout the organization. As a senior executive they can request detailed reports and other work from departments such as finance, coding, and strategic planning. They also have the expertise to understand the information provided in the broader context of the overall business practices of the organization. Most importantly, their primary training is in the area of theology and ethics and so they can interpret and apply this information in light of the organization’s raison d’etre, making recommendations or illuminating a perspective based upon the espoused values and purpose of the institution. While it would be foolish to think that any one person can dictate practices to a large and complex organization, the mission leader typically possesses a great deal of influence. This influence comes from the moral suasion of being able to call others to be part of a larger tradition that sees healthcare as a profession and ministry of service, just as many others saw it before us. Furthermore, there is the credibility of being part of the ongoing deliberations to address the constant challenges posed by the contemporary competitive healthcare environment. The skilled mission executive generally learns that he or she cannot always claim to pronounce solutions from the moral high ground but must respect that many considerations and viewpoints must be reconciled. Whither the Ethics Committee? Does this mean that ethics committees can have no role whatsoever in regard to organizational ethics? We believe there are two appropriate roles for HECs in this regard. First, as we noted earlier, the very work of ethics case consultation may point out structural barriers to carrying out the mission of the institution. The most obvious examples may concern the lack of appropriate palliative care services for patients near the end-of-life or appropriate home care services for persons who face discharge from the hospital. But, difficulties in reporting structures and other communication mechanisms as well as a host of other issues may surface in the conduct of case consultations. It is the duty of a HEC to establish an appropriate reporting relationship with a mission leader or other senior administrator who can be a part of ameliorating the problem. That is, HECs should not engage in the false dichotomy that nothing can ever be done about structural issues or that the only way something could be done is if the HEC is made responsible for organizational ethics. The third way, the responsibility of the HEC, is to find ways to help the voices of those who are poorly served to be heard by those in senior administration.
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Second, the ethics committee’s relationship with a mission leader or other senior administrator should be one of reciprocity. The mission leader should be open to the insights that surface directly from the work of the HEC. And, the mission leader should see the ethics committee as a source of potential liaisons to the front line providers. As such, the mission leader should help to make the reasoning and deliberative processes of management transparent to the committee and to other bodies of moral leadership within the institution. In this process, the mission executive will be open to feedback on decisions and performance. This dialogical process will help to build support within the institution for tough choices rather than to see them as simply imposed without concern for those affected. In sum, organizational ethics will not suddenly provide a way to overcome failure to thrive syndrome for ethics committees. In fact, it may exacerbate the problem if seen as such. However, we believe that non-profit healthcare institutions, in general, can be improved by following the example of Catholic healthcare and developing a structure such as a mission leader. In this structure ethics committees may find a kindred soul and an ally in dialogue. REFERENCES Andre, J. (2002). Bioethics as practice. Chapel Hill: University of North Carolina Press. Fox, E., Myers, S., & Pearlman, R. (Forthcoming). Ethics consultation in U.S. hospitals: a national survey. American Journal of Bioethics. Grant, M.K. (1999). Mission at the millennium. Health Progress, Mar/Apr, 18-20. Joint Commission on Accreditation of Health Care Organizations (2006). 2006 Comprehensive accreditation manual for hospitals: The official handbook (CAMH). Chicago: Joint Publication Resources. Kuczewski, M.G. (1999). When your ethics committee fails to thrive. HealthCare Ethics Committee Forum, 11(3), 197-207. Nelson, S. (2001). Say little, do much: Nurses, nuns, and hospitals in the nineteenth century. Philadelphia: University of Pennsylvania Press. Ross, J.W., Bayley, C., Michel, V. & Pugh, D. (1986). Handbook for hospital ethics committees. Chicago: American Hospital Publishing. Ross, J.W., Glaser, J., Rasinski-Gregory, D., Gibson, J.M. & Bayley C. (1993). Health care ethics committees: The next generation. Chicago: American Hospital Publishing.
