Living Ethically Within

Healthcare Organizations
Objectives
The reader should be able to:
• List several areas of healthcare addressed by organization ethics.
• Define the term mission statement and the role of a mission
statement in an organization.
• Describe what policies are and what they are designed to
accomplish within healthcare and other organizations.
• Identify how the utilitarian approach to policies and practices
serves everyone well and the conditions under which serious
shortcomings may arise from relying solely on this approach.
• Describe several ethical principles that are useful in the analysis
of organization ethics problems.
• Identify and discuss rights of professional employees in
healthcare organizations.
• Name some virtues of organizations and why they are important
in today’s evolving healthcare system.
• Compare basic values of health professionals with those of
healthcare organizations and strategies for bringing the two into
agreement around their common goals.

NEW TERMS AND IDEAS YOU WILL

ENCOUNTER IN THIS CHAPTER
organization ethics
mission statement
policy

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 conflict of interest
conflict of loyalty
stakeholder
cost-effectiveness
Patient Protection and Affordable Care Act
principle of participation
principle of efficiency

Topics in this chapter introduced in earlier chapters

Topic Introduced in chapter
Values and duties 1
Moral agent 3
Moral distress 3
Ethical dilemma 3
Locus of authority considerations 3
Virtue 4
Prima facie and absolute duties 4
Utilitarian theory 4
Principles approach 4
Beneficence 4
Nonmaleficence 4
Justice 4
The six-step process of ethical decision making 5
Moral courage 6

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Introduction
So far, we have focused on the ethical challenges that individuals
and interprofessional care teams face in their professional roles and
work environment. In this chapter, we turn more directly to the
organizational dimensions of healthcare. The suggestions in the
previous chapter regarding your ethical survival are not complete
without including your placement within the larger organization of
healthcare and the challenges it presents. Thus, another critical area
of ethical reflection in healthcare is organization ethics. Organization
ethics pays attention to the values, needs, traits, rights, and duties
expressed in:
Mission statements
Policies and other administrative arrangements
Business practices
Organization ethics cuts a wide swath across your professional
life. The field addresses ethical issues in the institutional structures
that deliver healthcare or are involved in remuneration for
professional services, agencies that regulate health professionals or
healthcare practices, professional associations, businesses that
provide healthcare equipment or material for procedures, and
pharmaceutical companies. Subsets of organization ethics are
business ethics, management ethics, administrative ethics, and
legislative ethics, to name some. Each addresses the conditions
under which an organization’s and society’s moral expectations can
be reconciled. They focus on the larger societal and bureaucratic
organization of modern healthcare; therefore, goals are not limited
solely to the ethical goals of individual health professionals and
teams.1 At the same time, often in the cases we have already
presented, we note that in addition to what is accomplished at the
point of decision making, institutional policies and actions impact
patient care, so the outcome in part is determined by the
relationship between healthcare organizations and its professionals.
For instance, a business goal of increasing the profit margin each
year is legitimate for a business enterprise. Business ethics

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addresses the conditions necessary for that profit margin to be
gained, with adherence to high ethical standards set by the
consumers of the business’s products or services, society, and the
organizations themselves. Healthcare organizations have ethical
problems that in many ways are similar to good business
management anywhere, but because of the special place the
professions have in society, these organizational structures must be
styled to fit the type of role its employees and clients play. The
“product” of the professionals’ skilled efforts is optimal patient care
outcomes. As a participant in various healthcare organizations,
your challenge is to assess whether their values, rights, and duties
affect your ability to achieve this end with patients when measured
against the standard of your professional values, rights, and duties.
To illustrate one version of how the ethical challenges of working
within an organization affect health professionals, consider the
following story, which serves the purpose of showing how
professionals’ tasks sometimes may appear to be removed from an
individual patients’ well-being but always are informed by that
purpose.

The Story of Simon Kapinsky and the

Interprofessional Ethics Subcommittee
to Implement a Green Health Plan
The chief executive officer (CEO) of StarServices, Inc, a for-profit
major health plan, has asked Simon Kapinsky, a senior member
of the professional staff in one of the plan’s units, to chair an
interprofessional ethics subcommittee of the health plan’s
greening advisory council. The advisory council recently was
formed to set new policy and practices for StarServices, Inc to
operate as a “green health plan.” The CEO explains that the
council decided an interprofessional care team made up of
several leaders of the unit’s clinical departments should be in
charge of assessing the clinical implications of this change in
regard to the health services it offers. On review of the material
from the CEO, Simon learns that the board of trustees of the

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health plan signed a contract 2 years ago to build or remodel all
of its treatment (not research) units according to principles of
ecologic architectural design. Simon is aware that the flagship
hospital in the health plan (where he is employed) already has
undergone major renovation, but he was not fully aware of the
scope of the project. In the proposal, the greening of the health
plan is being financed one-fourth by StarServices, Inc, one-half by
municipal bonds in the city where the major institutions of the
health plan are located, and one-fourth by Green International, a
private architectural firm whose purpose is to showcase ecologic
architecture in public buildings. Green International claims that
the new health plan structures will become the showcase for
ecofriendly medical facilities over the next 50 years. The
estimated overall cost is $46 million, but Green International
emphasizes that much of that cost will be recovered by offsetting
operating costs and also by the amount of business this
ecofriendly model project will generate. When Simon returns the
material to the CEO, the latter emphasizes, “With our flagship
hospital in the health plan already partially renovated,
StarServices, Inc is positioned to move ahead substantially
toward its strategic goal of becoming the greenest health plan in
the world. Now the next step is to rescale our clinical services
according to the overall ecologic impact of the range of clinical
services we offer. We can do well financially by doing what is
right for the environment! As you are the chair of the
subcommittee, we look forward to you becoming a member of
the advisory council; you will meet with us to keep us up-to-date
on your subcommittee’s findings and recommendations. Of
course, all members of your team will receive release time from
their clinical duties during this period as we at the top are aware
of the immensity of the task we are asking of you.”
Simon is not exactly thrilled at the prospect of chairing this
subcommittee, but with his CEO appointing him to the post, he
also feels that he does not have any good alternative but to
accept. That night, he goes home and discusses it with his
partner, who is also a health professional. Over dinner, they
come up with some questions that Simon will urge the
subcommittee to raise about the project. They agree that as

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concerned and ethically informed professional leaders, they have
more to take into account than to jump on the bandwagon of
excitement about being the “greenest health plan in the world,”
as laudable as that goal is.
Some of their questions include:
• Should a healthcare plan alter or select its range of patient
services on the basis of environmental ecologic impact?
• Assuming that the decision has been made to take this
approach:
• Has the organization already developed its own set of criteria
for selecting the current clinical services that will be
discontinued, and if so, what are they?
• Which specific services or categories of patients that could be
excluded would raise the most concern for the administration
(if any), and is the administration willing to consider keeping
these groups in the plan at the price of ecologic efficiency if
the subcommittee recommends it?
• If the subcommittee can come up with a plan, is the
administration willing to consider ways to honor the goal to be
“green”—or even “the greenest”—without tinkering with the
types of patients or range of services currently offered?
At the first meeting of the interprofessional ethics
subcommittee, Simon is gratified to learn that all of them have
some of the same questions as well as some other concerns. They
wonder whether or not every stone has been turned to look for
cost-saving and ecologically responsible changes in the way
things are done at the various institutions of the health plan to
warrant this jump to a cut or cutback in direct patient care
services.
By the end of the meeting, the subcommittee is confident that
their questions raise serious enough concerns that they should be
submitted to the CEO and chairperson of the advisory council for
further discussion. Simon agrees to carry their request to the
chair of the advisory council and sends a copy to the CEO. He is
surprised when at the next meeting of the full council he notes

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that the subcommittee’s questions are not on the agenda and the
chairperson does not mention it.
Finally, Simon calls the chairperson. She says, “I have just been
writing a letter to you and the subcommittee thanking you for
your thought-provoking questions, and of course, the
administration shares your concerns or we would not have
chosen the best clinical leaders we could identify to carry this
aspect of the project forward. We recommend that you not delay
in the larger task of assessment and recommendations, rather to
be informed in your own thinking with respect to the important
issues you raise.” Simon responds with a stunned silence. The
chairperson, noting this, continues, “I think in time any ethical
problems your subcommittee thought may be barriers will iron
themselves out.”
Simon thinks it over, discusses it with his partner, and calls the
subcommittee together. They agree to take the advice of the
chairperson but not let go of their own questions, which they
believe are extremely relevant to the basic purpose of the
organization and their ability to keep optimal patient care at the
center of their discussions.

Reflection
Before reading on, write down all of the values and priorities
implied or expressed by the members of the administration.
Then, do the same for the interprofessional ethics subcommittee.
Administrative:
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Professional:
______________________________________________________________________

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______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

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The Goal: A Caring Response
We know that the health professionals on the subcommittee are
moral agents whose “voice” must reflect values, needs, duties, and
rights guided by the goal of a caring response in the health
professional and patient encounter. For the interprofessional care
team to be effective, patient-centered analysis and strategy must
govern their recommendations. The “voice” of the organization is
expressed through the administrators and others who look out for
the administrative interests of the organization (i.e., the CEO and
chief financial officer [CFO], trustees, and in privately owned
institutions, the stockholders). You can correctly think of them as
the moral agents charged with protecting the values, needs, duties,
and rights of the organization as a whole. Thus, you can expect
their analysis and strategy priorities to reflect their position and
responsibilities. In Chapter 2, you also learned that to live by the
goal of a professional caring response requires acknowledging that
care cannot be “bottled”; it must be tailored for each situation.
Right off, the subcommittee recognizes that in this situation their
care for patients includes accepting it as a sign of good faith on the
part of StarServices, Inc that administration included direct care
providers in the project, giving the members an opportunity to help
shape the plan. Of course, as one member of the subcommittee
added, “The proof is in the pudding!” as to how seriously their
recommendations will be taken. A third added, “So, let’s put the
right ingredients in the pudding!” Having generated this amount of
energy for what is possible, Simon reminded them of the
assumptions of a relationship-centered approach that you read
about in Chapter 2: What may seem conflicting purposes may be
brought together and finally reflected in a changed organization
overall. Simon concluded the meeting with encouraging them to
identify strategies to engage effectively with the administration,
thereby reassuring them that the priorities they were representing
would be recognized and their recommendations implemented.
What follows is the process this meeting initiated.

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The Six-Step Process in
Organizational Matters
Given that several moral agents are found in this situation, you will
gain some important insights by walking with Simon and the
subcommittee through their experience, with use of the six-step
process of ethical decision making as a framework.

Step 1: Gather Relevant Information

Where can Simon’s subcommittee go to gain support for the
professional values they believe they are trying to protect? We
propose that Simon and the subcommittee need to gather data in
different places than if the issue pertained solely to their search for
an optimal plan of care between themselves and their patients. As
noted at the outset of this chapter, the values and priorities of
organizations can be found in their mission statements, policies and
administrative practices, and business approaches.

Mission Statements as Relevant Information

A mission statement is an organization’s brief description of its ideals
and aspirations. Because a mission statement is stated in general
terms, the employee can tend to ignore it completely when
accepting employment. The mission statement drives an
organization’s strategic priorities, and it is from these values and
ideals that goals, behavioral objectives, and expectations of all users
(e.g., patients and all employees) are derived. Sometimes, the
values of the organization are reflective of religious assumptions. In
the United States, many hospitals and schools are owned and
operated by religious groups, a situation visitors to other parts of
the world may not see. Such an organization makes reference in its
mission statement to its understanding of the relationship of
humans to a higher being and each other and to the way in which
the organization views itself as participating in the larger spiritual
and social scheme of things. In contrast, the U.S. Veterans
Administration healthcare plan is an example of a government-

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owned and government-operated healthcare system, which now
partners with various private companies for goods and services.
One expects its mission statement to read quite differently from that
of a religiously based nonprofit healthcare organization. Box 8-1
contains an example of a simple, straightforward mission
statement.

Box 8-1

Mission Statement—Massachusetts
General Hospital
Guided by the needs of our patients and their families, we aim to
deliver the very best healthcare in a safe, compassionate
environment; to advance that care through innovative research
and education; and to improve the health and well-being of the
diverse communities we serve.
From Massachusetts General Hospital, Boston, available at
http://www.massgeneral.org/about/overview.aspx.

Reflection
What does this mission statement tell you about the nature of this
institution?
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
___________________________________________________________________
Suppose this is the mission statement of StarServices, Inc.
Does this statement say some things that would support the ethics
subcommittee regarding arrangements they can recommend

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 based on the organization’s mission? If so, what are they?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Go back to the subcommittee’s questions. Do any specific phrases
in the mission statement help provide a basis for taking the
question(s) seriously? Which questions are they?
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
Because mission statements are public documents that become
the basis for more specific policies and expectations, it is prudent
and responsible to check the mission statement with as much care
as possible before becoming part of an organization. This
checkpoint should enable you to avoid moral distress or ethical
dilemmas further into your affiliation with this body and its
policies and practices if you find you do not subscribe to the overall
nature of the organization’s mission.

Summary
Like codes and oaths for health professionals, a mission
statement is an organization’s public statement designed to
declare the type of organization it is, including its core ethical
purpose, values, and ideals.

Policies and Administrative Practices as Information

A policy is a statement designed to establish formal and informal
guidelines for practice within an organization. Obviously, policies
should be consistent with the values of the organization. They also

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should be specific expressions of how the ideals in the mission
statement can be carried out by the people in the organization and
how the organization hopes to attract or serve. If policies are to be
followed, they must also be clear, practical, flexible, and consistent
with the values of the people or groups to whom they apply.
Currently, policies in healthcare reflect both traditional
healthcare ethics and business ethics. The hospital administrator of
a religious group whose mission clearly was to deliver high-quality
patient care once commented, “No money, no mission.” The goals
of an organization are not fully met simply by focusing on the
model of a single patient and the health professional or
interprofessional care team. In fact, it is often at the level of policy
that goals for an individual patient’s well-being come into direct
conflict with business interests. We can feel certain that this concern
was high in the minds of the ethics subcommittee members, and
they wanted to hear from the administration that they could trust
that patient-centered values and practices would not be unduly
compromised. Such a concern was expressed when one of the
authors conducted a workshop in a private healthcare facility that
had adopted a “no AIDS patients” policy because of the high costs
of services for many such patients. The health professionals were
distressed because the facility was in the process of building a new
multimillion-dollar reception area and surrounding gardens with
the hope of its beauty being the draw to “beat out the competition.”
This decision by the trustees of the facility was interpreted by the
professionals as being a triumph of profits over patients, and still
they agreed that the patient load was down because of increased
competition in their geographic area.
The subcommittee will have to spend considerable time accessing
policies that pertain to patient care in StarServices, Inc. Some of
them will include statements of patient rights introduced in
Chapter 2 and include protections for and responsibilities of
professionals administering care. Statements in these key
documents also can provide substance to the approach they take.

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 Summary
Few health professionals today are in situations in which they
can ignore organization policies. Still, professional values must
guide their own decisions.
As you recall from Chapter 5, step 1 of the six-step process of
ethical decision making includes identifying the facts, including the
relevant stakeholders and contextual factors in the problem you
face. The organization is a stakeholder, and a policy in that
organization is a contextual factor. The Realm-Individual Process-
Situation (RIPS) model of ethical decision making developed by
three physical therapists maintains that partially because of the
changes in the healthcare system, almost all ethical issues that
involve patient care now also have business or administrative and
larger societal dimensions.2 Similar to the work of Glaser,2 their
three realms of ethics (individual, institutional [i.e., organizational],
and societal) must be identified for their relevance.3 Reflecting on
these realms as a schema can be helpful in framing the ethical
decision-making process for individual health professionals and
members of the interprofessional care team (Figure 8-1). This type
of template also is useful to the subcommittee as they gather
information.

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 FIGURE 8-1

Step 2: Identify the Type of Ethical Problem

Simon and his colleagues on the ethics subcommittee of the
greening advisory council are experiencing moral distress. Their
guts tell them that something may be wrong in the whole approach
StarServices, Inc is taking in its pursuit of an otherwise laudable
goal of becoming “the greenest [healthcare] plan in the world.”
They also feel the pinch of an ethical dilemma. On the one hand,
they recognize that they have a duty of loyalty to the goals of their
employing healthcare organization, StarServices, Inc. Honoring its
organizational goals is an expression of these employees’
willingness to acknowledge that being an employee provides the
context for them to make a living while honoring their professional
commitments. They are brought face to face with the reality that the
values, needs, duties, and rights of the organization must be taken

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deeply into the equation as a part of their overall analysis. At the
same time, they know that they have a responsibility to how that
loyalty is expressed in light of the current challenge they face. They
were placed in a consultative role and asked to make
recommendations to help ensure that the health plan succeeds in its
worthwhile project, but their dilemma is in knowing that this
project’s success could come at the cost of compromising a caring
response to patient groups that use the facility. At this point, they
are on the horns of a dilemma with two right courses of action
facing them—one being their loyalty to the organization, and the
other, more compelling, their loyalty to the well-being of patients.
The subcommittee is facing the possibility that they are involved in
a serious conflict of interest situation. A conflict of interest—or as it is
sometimes correctly identified, a conflict of loyalty—occurs for
professionals when they are in situations that significantly threaten
their professional duties and commitments.4
Simon and the subcommittee also must consider the differences
in decision-making authority between them and the administration.
Although aware that their role ultimately is advisory, they believe
that they bring an essential ethical perspective and area of expertise
to this business enterprise. In fact, they were appointed to do so.
Their positions as leading professionals in this organization should
give them the say-so to have their recommendations taken seriously
by the administrators and advisory council. In fact, their concerns
are based on thoughtful ethical reasoning, which causes them to
take seriously their moral agency as guardians of patients’ well-
being. They believe they are on solid ground regarding their
assumption that this healthcare organization should protect quality
care for patients above all other priorities.
One important lesson the subcommittee members are learning is
that there are many stakeholders in the type of project they have
been pulled into, with different and sometimes conflicting values
and priorities. A stakeholder is a person, group, or other entity that
has a deep and compelling interest in a situation that it wants to
protect. Because ethical issues are involved, the stakeholders all are
moral agents with their part to play in arriving at ethically
acceptable courses of action. Two major stakeholders are the

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professionals and the administration or management. In order of
priority, some common loyalties that cause ethical conflict between
health professionals and the top-level administration of a healthcare
organization are listed subsequently.
Where Do Health Professional and Organization Priorities Lie?

Reflection
In examining these two sets of loyalties, where, if any place, do
you see complementary interests where the administration of
StarServices, Inc and the ethics subcommittee of professionals are
likely to find common ground for discussion and eventual
agreement? List them here.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
Why have you chosen these? Describe in a sentence or two
before going on.
______________________________________________________________________
______________________________________________________________________

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______________________________________________________________________
______________________________________________________________________

Step 3: Use Ethics Theories or Approaches

to Analyze the Problem
Several ethical approaches can be considered when a policy or
procedure proposal is being assessed, and the interprofessional
ethics subcommittee goes to work on this part of their task.

Utilitarian Reasoning in Organization Ethics

Utilitarian reasoning is the usual approach to a potential structural
change in an organization. Understandably, from the
administrative and business standpoint, an ethically supportable
policy or procedure is one that brings about the best outcomes
overall based on a utilitarian value system designed to provide the
greatest good for the greatest number. It follows that from an
organizational standpoint, considerations of individual autonomy
may be submerged in favor of such utilitarian considerations as
efficiency of operations and economic stability. Simply stated, the
organization that fulfills its function of providing a worthwhile
service efficiently usually is believed to justify the means used to
attain that end so long as the net result is a greater balance of
benefits to humanity than would be realized if the organization did
not exist.
The idea of cost-effectiveness often is cited as the appropriate goal
of health plans. A definition of cost-effectiveness is that the greatest
quality of care possible is provided at the lowest price. No one can
argue with that underlying utilitarian ideal. As you know,
however, the ethics subcommittee wants to be sure that the
administrative arrangements, however laudable, do not succumb to
the serious criticism that such efficiency can best be achieved
through cutting costs by means that unnecessarily compromise
high-quality care. They know that successful institutions today are
influenced by the idea of being “fit for purpose,” meaning that the
organization itself is responsive to particular needs and priorities of
the public it services, and this, in turn, requires that all institutional

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arrangements are geared ultimately to that end.5
Taking these general considerations into account, the combined
group can profitably discuss the question of whether StarServices,
Inc’s proposed course of action to cut back or cut out some services
appears to encourage practices that will do more good than harm
overall. No one will argue against the idea that a green organization
is a benefit to the environment and to the community and, from a
market competition and community support standpoint, benefits
the organization greatly. The ethics subcommittee is convinced that
the burden of proof on the organization is to show that the goal of
high-quality patient care is protected and encouraged.
The criticism often leveled at pure utilitarian thinking generally
applies to the current situation under discussion. The policy or
procedure that works as a general touchstone cannot provide the
optimal solution to every situation. It may be inappropriate or
inadequate to handle specific problems faced by the organization
and its constituents. Therefore, the utilitarian equation merely
provides boundaries. We all find ourselves breaking general
guidelines when overriding them is ethically justified—for
example, parking in a no parking zone to assist at the scene of an
accident. That is, of course, why there is a prima facie, but not an
absolute duty, to honor organizational arrangements based solely
on utilitarian reasoning. What may be best for most people most of
the time may not be best in a specific situation. It is from this level
of concern about whether a caring response to individual or groups
of patients will be compromised that the addition of several ethical
principles helps to enrich and fill out the ethics subcommittee’s
ethical analysis.

Principles Approach in Organization Ethics

From a principles approach, several ethical principles can further
delineate values and duties to which this particular organization
must answer.
The principle of beneficence is one key. Although utilitarianism
emphasizes overall good consequences that are brought about by a
course of action, beneficence requires the moral agents to delineate

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the type of good that the act itself is. For instance, consider specific
benefits that may be a part of the combined group’s discernment
about the next step. If a proposed course of action allows some
members of the organization to be exemplars in terms of improving
patient satisfaction while increasing employee morale and
demonstrating good stewardship of environmental or other
resources, these specific benefits can be heralded apart from the
overall good consequences.
The principle of nonmaleficence also is an essential corrective to
utilitarian theory used alone. The administration that creates moral
distress by ignoring the voice of concern brought by thoughtful
professionals such as the ethics subcommittee is harming its
employees and risking a decrease in professional staff morale more
widely. Moreover, as StarServices, Inc looks toward implementing
its ideal of a green healthcare organization, the combined group of
administrators and subcommittee members must work together to
minimize undue harm that would ensue through new policies and
procedures, practices, or resource priorities. In this case, part of the
harm would be a compromise of the professionals’ ability to bring
about optimal patient care policies and practices because of
inappropriate cuts in goods or services.
The philosopher John Rawls, to whom you were introduced in a
previous chapter, holds that the principle of justice is a fundamental
virtue of institutions. His position is that if an organization is fair in
its assignment of rights and duties and makes provision for a fair
distribution of its resources, then all individuals in those
institutions will be able to live more moral lives.6 If the
administration of StarServices, Inc can show that its proposed
course of action will continue to honor the distribution of patient
care resources based on patient-centered considerations of need
(rather than on market and other business benefits alone), a major
concern of the ethics subcommittee can be laid to rest.
The principle of respect also is relevant. All stakeholders in this
situation deserve respect. The interests of administrators and
trustees counsel toward a green organization because it shows
respect to the larger community through saving and protecting
natural resources and by being accountable regarding health-

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related environmental pollution and other harms. They are aware
that healthcare institutions are among the highest waste-producing
and toxin-producing entities and are committed to demonstrating a
viable alternative.7 The professionals’ goal of showing respect for
patients can factor in benefits to the latter that a greener workplace
will provide. At the same time, this interprofessional subcommittee
comprises a team that is well positioned to keep the patients’ well-
being tantamount, creating a reasonable expectation that their
recommendations always will keep professional values and duties
at the center of their work. This is a strong argument in the
subcommittee’s favor that whatever change is made in patient care
services, it does not compromise the professionals’ duties of a care-
centered workplace.

Summary
Utilitarian reasoning almost always must be used to determine
the best possible balance of benefits over burdens when
organizational policies and procedures are being implemented.
At the same time, principle based approaches that involve the
dictates of beneficence, nonmaleficence, justice, and respect
considerations refine the ethical analysis in a specific situation to
guide decision makers.

Step 4: Explore the Practical Alternatives

The subcommittee already has done considerable work on their
task. They have examined organizational documents and policies
that support their position, identified needs, duties, and relevant
ethical principles which they believe should govern future action
from the standpoint of their professional role as moral agents. They
have taken into account that “the bottom line” of money does
matter in organizations and that administrative decisions always
must keep “the big picture” in focus, weighing the costs of one
priority against another and honoring the importance of efficiency
within the organization as a whole. Although they have concluded
that a utilitarian approach is not alone a sufficient basis for ethical

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analysis, they agree that it is one critical aspect of ethical concern
when it comes to an organization’s general positions, policies, and
practices. But they also have reckoned with the moral rights and
reasonable expectations with which they undertook the
responsibility of trying to help address a major change in the
character, public image, and internal practices of StarServices, Inc.
In all of this, they have moved forward believing that through their
diligence the top administration and trustees will have an
opportunity to foster an environment consistent with the high
moral and service standards of patient-centered healthcare. Note,
too, that they did not refuse to participate in this important
planning, even though they did not feel completely supported at
the outset. They showed up and worked diligently to create a
context in which everyone involved has a chance to bring their best
thinking and core priorities to the table of negotiation. Now they
have convened again to hone in on the alternatives they see in
framing their recommendations.

Reflection
List some practical alternatives that you think Simon and the
ethics subcommittee have open to them.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
We see the following alternatives:
• Surely one course of action is to do nothing more than submit
their recommendations at the level of the framework for ethical
decision making they have deployed and turn the strategic
next steps over to the administration.
• Simon may continue to attend the meetings of the greening
advisory council and communicate privately with the CEO and

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 chairperson of the council to become the point person for the
ethical reasoning that will inform future decisions about how
to address clinical services within the new “greened” system.
He can also seek guidance from an ethics committee in his
place of employment for further insight into how to proceed.8
• The whole subcommittee may now move vigorously to the task
with which they were originally charged by choosing to focus
on research findings from other green healthcare institutions
about how they reckoned with their mission of maintaining or
improving quality care; by appealing to government and other
agencies for information regarding environmental issues
related to healthcare procedures; and by a more service-by-
service assessment, asking the CEO and council for the
appropriate documents, experts, and staff support to engage in
a thorough study of possible areas of waste or administrative
“fat” that could be eliminated without altering quality care.
• A version of the previous alternative is to recommend that the
current subcommittee be refocused, with some members
remaining and others being added to discuss their
understanding of how quality care can best be maintained or
enhanced across the organization while educating them to the
larger goals of the greening project.

Steps 5 and 6: Complete the Action and

Evaluate the Process and Outcome
We do not know which of these alternatives the subcommittee will
pursue. Note that each alternative involves their willingness to
move ahead in the face of some unanswered concerns, to put their
best effort into honoring their professional loyalties while
respecting key organizational concerns, and to develop an ethical
framework that can be applied to many specific decisions. Notably,
they also have interpreted their task in such a way that their moral
agency has not been compromised, courageously rising to the
challenge of patient advocacy in a changing environment where
policies and practices seem at odds with the demands of their moral
roles. Importantly, by all of these means, they have avoided

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experiencing a feeling of loss of control, stress, discontent, and
disheartenment.9 The ethics subcommittee’s goal to help set
direction that upholds the organization’s high ethical standards of
patient care is on its way to being realized.
As with all important ethical challenges, their willingness
eventually to reconvene as a “reflection group” (see Chapter 6) to
evaluate the process and outcome of their experience will
strengthen them for future leadership efforts within their
organizations. Moreover, they can find ways to share their
successes with other staff and health professions groups attempting
to deal with similar challenges regarding the increasingly rich mix
of priorities that health plans are facing.

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Educating for Moral Agency Within
Organizations
As an educational opportunity, at least two areas of their ethics
subcommittee experience may make good professional staff
seminars in their workplace or at meetings of their professional
organizations. We conclude this chapter with introducing them
here.

Living with the Business Aspects of

Healthcare
Healthcare organizations are businesses, but not only businesses.
Bodenheimer and Grumbach10 maintain that the following three
major forces drive the organization of healthcare in the United
States and, to some degree, in all economically developed nations:
(1) the biomedical model, (2) financial incentives, and (3)
professionalism. The service of healthcare is expressed through the
biomedical and clinical skills of the professionals, the financial
grounding through financial incentives, and the particular ethical
standards through professionalism. Still, the financial incentives
often are targeted in the literature as creating the biggest challenge
to the professionals. In other words, the challenge for health
professionals is the requirement of living with the “business” of
healthcare but not letting it govern all the values and priorities of
practice.
Business language often conjures up negative images of greedy
healthcare institutions driven by profit at all costs. Such
organizations do exist and, of course, create ethical dilemmas for
any health professional who works in them because they fail to
meet reasonable expectations of patients and society. Not all
healthcare institutions, however, are driven solely by a monetary
bottom line. Many healthcare organizations are distinguished by
their vision, mission, and sensitivity to the implications of each
when making decisions about the business. The business functions

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of any organization are designed to help meet the appropriate goals
of that organization, whatever those goals may be. An examination
of the priorities of an organization in chart form earlier in this
chapter highlights why some major themes in business ethics are
honesty in advertising, transparency in dealings with partners and
clients, fairness in the treatment of employees and others, criteria
for quality control of the product or service, the meaning of fiscal
accountability from the standpoint of taking everyone’s legitimate
interests into account, and the duty of respect for others in all the
organization’s interactions.

Healthcare Reform
The healthcare delivery system is continuously evolving. The
passage of the Patient Protection and Affordable Care Act of 2010
marked a major shift in recent trends in the United States, which
was moving from treating healthcare as a commodity, back to
seeing it as a right. This landmark legislation had three main goals:
to expand access to health insurance, to protect patients from
arbitrary actions by insurance companies (such as refusing to cover
individuals with preexisting conditions), and to reduce costs. The
Affordable Care Act (ACA) and other health reform initiatives have
incentivized integrated and coordinated care delivery, changing the
way care is delivered across multiple settings and organizations.11
Alternative payment models and value-based payments are being
introduced, and payment is being linked to outcomes under the
Medicare program. Although a full discussion of the ACA is
beyond the scope of this book, note that the emphasis on
measurement of quality and patient experience will hold
organizations (and the leadership of these organizations)
accountable to navigate change and ensure that ethics is central in
all decisions regarding care redesign and the delivery of care.12

Reflection
Specify some ways a healthcare organization such as a health
plan, hospital, nursing home, or home health agency has to gear

316
its business goals, policies, and practices to meet high ethical
standards of patient care.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
To thrive ethically within the organization where you work, you
need to identify the business realities and critique them. Although it
goes beyond the parameters of this book to fully address the
business dimensions of your practice setting, the next generation of
health professionals, to which you will belong, will be forced to be
more cognizant of them. One of the most interesting challenges for
you is that the organizational structures in which you may find
yourself are much more diverse than even a few years ago. For
example, in addition to the more familiar settings of a hospital,
clinic, rehabilitation center, school system, home health agency, or
hospice, you may be working aboard a cruise ship, in the military,
at a children’s camp, with a sports team, or for a retail corporation.
In each instance, your professional values must be honored and the
business aspects of the workplace understood for how well they
match up with the demands of the health professions.

Summary
Both a firm grounding in professional ethics and astute
awareness of the business dimensions of healthcare are necessary
for a full picture of ethical problems in today’s healthcare
organizations. Organizations should be shaped by patient-
centered healthcare arrangements.

Rights of Professionals in Organizations

The ultimate administrative decisions in most organizations are
made by those in leadership positions within the structure,

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although today multilevel input sometimes is invited. The greening
advisory council and its ethics subcommittee are examples of
StarServices, Inc’s mechanisms to invite multilevel input. In other
words, more and more people from all echelons of an organization
hierarchy are currently being recruited to provide input and share
governance in administrative decisions.

The Right to Participate

This stance is consistent with the idea that everyone in an
organization has a basic moral right to become involved in
appropriate ways. The moral principle of participation is seldom
included in lists of ethical principles applicable to healthcare ethics
but is often cited in social ethics and political treatises on
democratic societies. It arises partly from the more familiar
principle of autonomy because it supports the idea that you, in your
role as a professional, have a right to help determine aspects of your
workplace that directly affect your well-being. Your involvement in
organizational arrangements and the review of practices or policies
are the only ways you can ensure that you will not be forced to
sacrifice important personal and professional values to overriding
organization values such as efficiency. Workplace efficiency can be
applauded when it is brought in line with the professional values of
faithfulness to patients’ and professionals’ rights and prevention of
harm to anyone. But only with participation of concerned
professionals is that outcome assured. Simon and his colleagues
were offered—and took—the opportunity to participate in ensuring
that patient-centered care was not compromised.
A good place for you to start exercising your right of
participation at the organizational level is in your own place of
employment or your professional association. Part of the ability to
be involved in policy is to be able to ascertain where organizational
arrangements are being made and revised. Pertinent questions
include:
1. What are the names of groups responsible for making
organizational arrangements and setting policies and
practices? To whom, exactly, does each report?

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 2. Who sits on the organization’s various committees, and what
are their qualifications?
3. What must you do to be nominated for or appointed to a
group?
4. To whom must you speak to learn more about a group and
express your interest?

The Right to Employment Protections and Guidance

It is your right to assume that your organization will have a range
of policies and other administrative arrangements that give clear
direction for you to practice ethically. Depending on the nature of
your patient population and the services offered through the
organization, you should be able to find the following types of
policies or guidelines related to patient care:
• Informed consent policy
• Withholding and withdrawing life-sustaining treatment policy
• Assisted suicide and abortion policies
• Advance directive policy
• Surrogate decision making, healthcare agents, durable power of
attorney for healthcare, and guardianship process policies
• Do not resuscitate (DNR) policy
• Confidentiality and privacy policy
• Organ donation and procurement policy
• Human experimentation regulations (policies and procedures)
• Conflicts of interest policy (including patient care and research
policies)
• Patient admission, discharge, and transfer policy
• Impaired providers policy (including reporting procedures for
impaired professional colleagues or preventable adverse
events)
• Conscientious objection policy and procedures

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 • Reproductive technology policies
• Grievance procedures

Reflection
Can you think of other policies, procedures, or guidelines that
pertain to your professional responsibilities?
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________

The Right to a Virtuous Organization

As you recall, virtue theory provides tools to examine the type of
person one ought to be. Philosophers, economists, and others
acknowledge the power of organizational structures to affect the
lives of individuals in our highly bureaucratized society. You have
a right to be assured that your workplace administration shows
sincere and intense commitment to creating a humane or “virtuous”
organization. Because most organizations are governed by a small
number of people who have the final say over what happens to
everyone, this commitment must begin with the individuals who
have the most power and authority. The interprofessional ethics
subcommittee in this chapter recognized the difference in decisional
authority between the top administration and themselves. The traits
of healthcare organizations are one important focus of serious
reflection today, and we invite you to participate in this exciting
dimension of your professional career.
You already have learned that efficiency is one virtue of
organizations because they are designed to meet multiple needs
and render multiple services. The principle of efficiency can provide a
moral basis for conduct that benefits all. From a social standpoint,
many say that a “good” or “well-run” organization is an efficient
one. From the standpoint of your tasks within a healthcare

320
organization, however, you benefit from institutions and systems
that reflect other virtues too.
For example, you have also already learned in this chapter that a
commitment to justice in the organization’s assignment of benefits
and burdens is a virtue that organizations can strive to meet.
Can you imagine what a courageous organization is like and
what type of policies and administrative guidelines you can find
there? What about a compassionate or merciful institution? You can
help to construct policies, practices, and other arrangements that
allow your workplace to exhibit a commitment to organizational
virtue.

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Summary
Organizations have a moral obligation to help prevent destructive
conditions from occurring to their employees and others who make
up the organization. Because so many people spend more time each
week in the organizations of work than they do in their own homes,
all organizations must assume an influential role in helping to
foster high moral standards.
This chapter takes you, the moral agent, out of the one-on-one or
team clinic environment and into the committee room and
administrator’s offices where a new interprofessional team of
clinicians is called upon to help meet an organizational goal. As the
complexity of the health professions and healthcare environment
continues to grow, so do the necessity and opportunity for
becoming involved in the development of mission statements,
policies, and administrative and business practices. Such
involvement should enable you to maintain professional standards
and a high level of ethical practice. The six-step process of ethical
decision making can guide you in your role in this situation.
Despite the help that the organization’s policies, practices, and
environment can provide, they are not an automatic guarantee of
high-quality patient care or fair practices toward employees,
patients, or others. You still must apply skillful ethical reasoning
about ethical problems as they present themselves.

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Questions for Thought and
Discussion
1. Can you describe an employment situation in which you can
imagine quitting in protest over an ethically unacceptable policy of
the organization? What is it? List the pros and cons of quitting.
Now list some changes that would allow you, in good faith, to
continue in the organization.
2. You are part of the interprofessional care team that works with
the autistic population in a charter school setting. Your program
has been highly sought out by parents of children with autism and
other developmental disorders, so much so that currently 10
students are on the wait list. The team receives a referral for a new
child to be transferred into the program. The child is placed on the
wait list, but the administration communicates a request to the team
to see whether there is “anyway they can accept the child now since
he is the grandson of one of the school’s employees.” The team is
split on what recommendation they should give. They deeply
regard and respect the child’s grandmother but also know that
several students are ahead of this child on the wait list and are
likely just as deserving. Should the team approve the acceptance?
Defend why or why not, drawing on the duties, rights, and role
issues discussed in your study of ethics so far.
3. Eudora Cathay has been a unit clerk at the same for profit
privately owned hospital in an affluent, largely white suburb for 2
years. The position of unit clerk is a demanding one that involves
answering the phone, relaying messages, coordinating laboratory
personnel in their rounds, responding to physicians’ and nurses’
requests, and making sure that patients are in the right places at the
right times. Eudora’s striking appearance is enhanced by her
African dress style. Some of the more conservative members of the
staff, particularly physicians and administrators, are disturbed by
her style of dress. Others find it attractive and an interesting change
from the wall-to-wall white uniforms worn by the professional staff
everywhere in the hospital. The dress policy does not require unit

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clerks to wear a uniform and stipulates only that they be neat and
well groomed (which she is) and dressed “appropriately” (which is
controversial). Someone in an administrative position asks Eudora
to dress more conservatively. She refuses on the grounds that she is
neat and well groomed and any further demands are an invasion of
her privacy. She is fired for her refusal to comply, amidst rampant
rumors of racism. Discuss her situation in light of good
organizational policy. Should there be a dress code? Is there
anything ethically relevant about how employees dress? Why or
why not?

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