An essential aspect in the original definitions of organisation ethics and in the standards of accreditation are mission and values. Most organisations have spent a significant amount of time developing their mission and value statements. An examination of four health care organisations in Ireland will identify these core values.
The Bon Secours Health System in Ireland (BSHS) is a private Catholic health care organisation. Its mission is to be a leader in Catholic Health Care in Ireland, to care for the sick, the dying and their families within a Catholic ethos. In developing core values, the BSHS states that the dignity and uniqueness of each person is recog- nised, and they seek to provide high quality, holistic care which is characterised by compassion, respect, justice and hope while maintaining a patient-friendly environ- ment in their hospitals. Through their mission statement they hope to empower staff to reach their full potential, reach out compassionately to the community and be innovative and responsive to new developments in health care.16
Beaumont University Hospital is a public teaching hospital with a mission to de- liver best quality of care to patients. It goes on to state that it is continually working to develop and to improve the way care is delivered and to enhance the environment in which members of staff work.17
St Vincent’s University Hospital in Dublin is a voluntary hospital.18Its mission is to strive for excellence in meeting the holistic needs of patients in a caring and healing environment in which the essential contribution of each member of staff is valued. The values of human dignity, compassion, justice, quality and advocacy, rooted in the mission and philosophy of the Religious Sisters of Charity, guide the work in St Vincent’s University Hospital. Within the foregoing context, the hospital makes every effort to maintain excellence in clinical care, teaching and research.
172 D. Smith, L. Drudy The Daughters of Charity Services for People with an Intellectual Disability19 give priority to people with the greatest need, and recognise that persons with intel- lectual disabilities possess a unique dignity and potential, and are committed to the promotion of justice and to develop this potential so that they can take their place in society in a meaningful way. Their core values are service, respect, excellence, collaboration, justice and creativity.
As can be seen from these four mission statements, certain values are common to all of them. They include the dignity and uniqueness of the patient, a holistic vision of care which encompasses compassion, respect and justice. There is also emphasis on collaboration between different professional groups as well as the empowerment of the staff and a desire to show that staff members are valued. They include the el- ement of research and teaching. They are all aspirational in that they want to deliver the best quality of care within their respective institutions.
What is also evident is that the ethos of the organisation is fundamental to how the mission statement and core values are developed and implemented. An organisation with a particular religious ethos does raise particular issues for the delivery of care.
One of the most common issues which arise in some institutions with a religious ethos is the non-therapeutic sterilisation of men and women. While the professional staff may be willing to deliver this service, the ethos of the hospital does not permit it. Another example would be the provision of assisted reproduction techniques such as in vitro fertilisation. Recently, there has been extensive debate regarding stem cell research in health care organisations which have a particular ethos.20Maintaining a particular ethos may be acceptable in a private facility in which the staff and patients are willing to accept the limitations imposed. But it becomes more polemical when the state is the major source of funding for the institution.
If the mission and values of an organisation are to be fundamental then they must influence the process to address ethical issues associated with the business, financial and management categories of health care as well as the professional, educational and contractual relationships affecting the operation of the health care organisation.
To develop and maintain a positive ethical climate, organisational ethical activities must encompass all these different aspects of the operation. It is here that there are areas of potential conflict.
The core principles of business ethics are common decency and justice. Yet, health care organisations are unlike other, non-health-care-related businesses and organisations in several ways. They are not identical to health care professional as- sociations and, as organisations, they are distinct from the professionals who provide medical care in these and other settings.
As a business, a health care organisation is distinctive in that the payer for ser- vices, be it the state or the insurance company, is commonly not the “consumer” of the service provided. This means that the major decisions about access to and cost of health care interventions are at least practically made by an entity that may be more interested in cost distributions than in the availability and quality of interventions for individual patients.21 Examples of this would be the decision not to make certain drugs available to patients or to limit costly procedures which will only benefit a small number of patients.
Corporate Culture and Organisational Ethics 173 In many other businesses, the role of each stakeholder (stockholders, customers, payers, employees, contractual partners, the local community and the larger soci- ety), can be clearly identified. Along with this identification comes mechanisms for each stakeholder to have appropriate decision-making authority in the aspects of the business that affect the stakeholder. This authority is maintained by the assigning of rights and responsibilities based on the particular role. This is made difficult in health care organisations because of the confusion of roles of the consumer (patient), the buyer or payer, the health care professional, and the manager. Organisational ethics must be able to address not only the often divergent interests of these in- dividuals and groups, but also the role confusion, the markedly different levels of power and authority, and the greater level of social obligation of the health care organisation.22
Traditionally, professional health care ethics is based on the ideal that a health care professional should always be an advocate for the particular patient and act in that patient’s best interest. The ideal of advocacy for individual patients has al- ways been and continues to be a strong influence on the perceptions and reality of modern health care. Health care professionals, who are employees or who have other contractual arrangements with a health care organisation, have their own sets of professional ethical obligations. These are independent professional standards, established by professional associations and cannot be controlled by the health care organisation, but are important factors in the care provided by any health care organisation. The ideal of advocacy for individual patients has always been and continues to be a strong influence on the perceptions and reality of modern health care.23
A good example of a professional’s responsibility to his or her patient is seen in A Guide to Ethical Conduct and Behaviour of the Medical Council of Ireland.
An examination of the ethical guide demonstrates that the doctor’s responsibility to his or her patient is always primary.24Similar views are also found in The Code of Professional Conduct for each Nurse and Midwife.25
Having briefly examined the role of the professional health care manager and the health care professional, we turn now to a third important constituent, namely, the patient. In different countries patients have formed organisations which demand that their rights are recognised in areas which were traditionally left to health care professionals. Patients’ rights movements have addressed important issues such as the process of informed consent and refusal, truth-telling and confidentiality. They have also been active in decision-making concerning futility of care and end of life decision-making. Individual access and allocation of resources have also been high on their agenda.
Health care managers are obliged to follow the rules of business and to put the good of the organisation to the forefront. They are also responsible to governmental agencies and the insurance industry for the way their institutions are administered.
Health care professionals, on the other hand, have traditionally put the good of the individual patient to the forefront. This could lead to a clash of values between management and health care professionals. The patient as a consumer is another interested party. Thus a three-way conflict can arise between the patient, the health
174 D. Smith, L. Drudy care professional and management or a two-way conflict between the patient and management. The most obvious area of potential conflict is in the allocation of re- sources. Areas where disputes commonly arise are in the area of transplant surgery, the management of Intensive Care Units, expensive experimental surgical proce- dures, recruitment of expertise which may not be a priority health need, care of the elderly and the prescription of expensive medication.
Yet a health care organisation’s primary mission is to deliver health care to pa- tients or a defined patient population. In health care, organisational ethics is the integration of patient values, business ethics and professional ethics. Organisational ethics must work to integrate these perspectives into a unified organisational pro- gramme that provides and sustains a positive ethical climate within each health care organisation. To achieve this, the organisation must institute processes to ensure that this definition is understood and advanced by all in the organisation.
One of the ways of ensuring that this process of integration is activated is through the establishment of Clinical Ethics Committees.26 These committees can address the threefold dimension of the organisation – patients, professional bodies and busi- ness. Generally these ethics committees, working within the mission and values of the organisation, commit themselves to the following functions: to provide support, consultation and clarification on emerging ethical issues in the delivery of con- temporary health care; to respond to appropriate requests for case consultation; to provide assistance and guidance in the development of protocols and procedures to members of departments and multidisciplinary patient care teams; to provide ed- ucation and reflection on ethical issues in health care, as well as guidance in the ethical aspects of the development of policies and procedures within a hospital;
to be a resource to staff, patient, doctors and the health care team; to ensure that all decision-making remains where traditionally it has been, i.e. with the patient, family, doctor and the health care team.
These committees have addressed a number of core issues which arise. Examples of this could be the issue of consent and confidentiality. They would also examine issues regarding Do-Not-Resuscitate directives. Issues concerning the allocation of resources are often examined. Access to cosmetic surgery is often discussed un- der the remit of the allocation of resources. Invasive cosmetic surgical operations performed on healthy bodies for the sake of improving appearance lie far outside the core domain of medicine as a profession dedicated to saving lives, healing, and promoting health. These cosmetic procedures are not medically indicated for a diag- nosable medical condition. Yet they pose risks, cause side effects, and are subject to complications, including pain, bruising swelling, discoloration, infections, forma- tion of scar tissue, nerve damage, hardening of implants, etc.27Moreover, cosmetic surgery is a consumer-orientated entrepreneurial practice, heavily promoted by ad- vertising. In an acute hospital, cosmetic procedures can make heavy demands on already stretched resources.
In some health care organisations which have a particular religious or cultural ethos, clinical ethics committees also attempt to ensure that the ethos of the organ- isation is maintained. This can be particularly difficult for a number of reasons. If the ethos of the organisation prohibits certain procedures which are perfectly legal
Corporate Culture and Organisational Ethics 175 in the State, how does it reconcile the state funding which it receives? Another issue which arises is the withdrawal of treatment from patients. If the clinical judgement is that the patient will not survive without assisted ventilation but the ethos of the institution demands that this be maintained, who makes the final decision? Often, in circumstances like this, the ethics committee’s role is to review the ethos and the current situation and attempt to give advice which is beneficial to the patient. In many instances the ethics committees are seen as the interpreters of the ethos.
Some clinical ethics committees also see a role for themselves in conflict resolu- tion between various constituencies. If developing human flourishing is understood to be an integral part of their functioning, then an ethics committee can ensure that by developing a good ethical environment, the organisation will project itself to the public as an ethical organisation which is good for business.
Conclusion
If organisational ethics is to have real meaning and the ability to carry out its man- dated tasks, it must be based on a mission and a vision of the ethical climate under which the organisation defines itself by its ethical values. The organisation must institute processes to ensure that this definition is understood and advanced by all in the organisation. This requires integrating and supporting patient, business and professional perspectives and mediating among them when integration or mediation is required to advance a positive organisational ethical climate.28
Notes
1. Irish Health Service Accreditation Board (2005), Acute Care Accreditation Scheme: A Frame- work for Quality and Safety, 86. Available at: http:// www.hiqa.ie/media/pdfs/acas standards2.pdf (accessed 27 June 2008).
2. E. Spencer, A. Mills, M. Rorty and P. Werhane, Organisation Ethics in Health Care (Oxford: Oxford University Press, 2000), 5–14.
3. http://www.dohc.ie/publications/madden.html (accessed 22 October 2007).
4. http://www.hepccomptrib.com/index.php (accessed 22 October 2007).
5. http://www.rlcinquiry.org.uk/ (accessed 22 October 2007).
6. http://www.bristol-inquiry.org.uk/final report/rpt print.htm (accessed 22 October 2007).
7. http://www.lourdesinquiry.ie/ (accessed 22 October 2007).
8. P. Manning and D. Smith, (2002) “The Establishment of a Hospital Ethics Committee”, Irish Medi- cal Journal Vol. 95. No. 2. 54–55.
9. T. Beauchamp and L. Walters, (eds.), Contemporary Issues in Bioethics (New York: Wadsworth Publishing Company, 1999), 18–23. For a more detailed analysis of these principles see R. Gillon, (ed.), Principles in Health Care Ethics (New York: John Wiley & Sons, 1994), 1–334.
10. R. Lifton, “Doctors and Torture” New England Journal of Medicine Vol. 351. 414–416. July 29, 2004.
11. Corporate tragedy refers to all disasters which befall businesses – from an explosion in a plant to an aeroplane crash – in which employees, customers or members of the public are killed, injured or otherwise put at risk. The Bhopal disaster in India in 1984 is a good example as are those of Enron and Parmalat.
176 D. Smith, L. Drudy 12. An Interfaith Declaration. A Code of Ethics on International Business for Christians, Muslims and Jews 1993 Amman, Jordan, http://astro.temple.edu/∼dialogue/Codes/cmj codes.htm (accessed 22 October 2007).
13. http://www.jointcommission.org/ (accessed 22 October 2007).
14. The Acute Care Accreditation Scheme – Standards and Guidelines: 2nd Edition. Irish Health Ser- vices Accreditation Board 2005. Available at: http:// www.hiqa.ie/media/pdfs/acas standards2.pdf (accessed 27 June 2008).
15. Joint Commission, Joint Commission International Accreditation Standards for Hospitals. (2nd Edition, 2003). Available at: http:// www.jointcommissioninternational.org/ (accessed 27 June 2008).
16. Bons Secours Ireland, http://www.bonsecoursireland.org/ (accessed 22 October 2007).
17. Beaumont University Hospital, http://www.beaumont.ie/ (accessed 22 October 2007).
18. St Vincent’s University Hospital, http://www.stvincents.ie/mission.html (accessed 22 October 2007).
19. Daughters of Charity Services for People with Intellectual Disability, http://www.docservice.ie/
(accessed 22 October 2007).
20. BioEdge has a series of articles which summarise the debate, http://www.australasianbioethics.org (accessed 22 October 2007).
21. E. Spencer, op. cit., 9.
22. E. Spencer, op. cit., 12–13.
23. E. Spencer, op. cit., 10–14.
24. Medical Council, A Guide to Ethical Conduct and Behaviour (Medical Council, 2004). Available at:
http:// www.medicalcouncil.ie/professional/ethics.asp (accessed 27 June 2008).
25. An Bord Altranais, http://www.nursingboard.ie/ (accessed 22 October 2007).
26. It is necessary to draw a distinction between Research Ethics Committees which approve therapeutic and non-therapeutic research and Clinical Ethics Committees. Clinical Ethics Committees are also called Ethics Forums, Ethics Committees and Service Ethics Committees.
27. K. Davis, Reshaping the Female Body: The Dilemma of Cosmetic Surgery (New York: Routledge, 1995), 27–8.
28. E. Spencer, op. cit., 14.