Susan H. Taft, PhD, MSN, RN
Ethical decision making and action in health care are complex phenomena. This article provides an inclusive overview of the domain of ethics, a discussion of the many origins of ethical values, and an historical overview of how ethics fits with the related domains of morality, religion, law, culture, professional codes of conduct, and policy. A case situation based on real events illustrates the ethical conflicts inherent to interdisciplinary health care administration, including the influence of power and money. The article seeks to facilitate ethical reflection in the health care disciplines, and to contribute to the level of discourse among professional care providers and their leaders. Ultimately, patients stand to benefit from our discerning choices.
Citation: Taft, Susan H. (November 8, 2000); "An Inclusive Look at the Domain of Ethics and Its Application to Administrative Behavior" Online Journal of Issues in Nursing; Vol 6 No 1. Available: www.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/TableofContents/Volume62001/No1Jan01/ArticlePreviousTopic/DomainofEthics.aspx
Key words: Ethics, managerial ethics, health care administrative ethics, ethical decision making, organizational culture, values, leadership, morality, patients and ethics, health care workers and ethics, domain of ethics.
This article's purpose is to clarify the domain of ethics, and to clarify that domain within the health care arena. The specific focus will be on administrative ethics, a less scrutinized area of ethical conduct and, in many ways, more conflicted by competing values than the area of biomedical ethics. While a nursing perspective is presented in the article, discussions of the ethical domain relate broadly to all health care workers.
After extensive reading of ethics articles written by nurses, ethicists, and other experts, including those appearing in the Online Journal of Issues in Nursing, this author found that the discourse in nursing assumes a shared understanding of what constitutes ethical decision making. It is my observation, however, that a common understanding of and agreement about ethics may be more wishful thinking than reality. Toward a goal of greater clarity about the domain of health care ethics, what follows in this article maps -- and hopefully illuminates -- the philosophical and cultural origins of ethics. Subsequently I examine how these ideas on ethics apply to administrative conduct.
When as a nursing management educator I began to incorporate ethics into my teaching, I discovered that there was little agreement in the nursing or management literature about what constituted the domain of ethics. Boundaries were difficult to draw around the concept (see Table 1). How does one differentiate ethics from morality? from law? How does religion relate to ethics? Unable to teach what I didn't clearly and fundamentally understand myself, I began an exploration in order to "get a handle" on this domain called ethics. What I discovered has enabled me, as both teacher and preacher of ethics, to be grounded in the historical origins of ethics, to be clear about its boundaries and its relationship to similar concepts, and to understand how one should use the information to drive managerial behavior.
It is common in nursing texts and articles to define ethics according to the principles of beneficence, nonmaleficence, respect for autonomy/self-determination, fidelity, justice, and veracity, and to draw from the ethical theories of utilitarianism and deontology (e.g. Brosnan & Roper, 1997; Davis, Aroskar, Liaschenko, & Drought, 1997; Ellis & Hartley, 1995; Silva, 1990). This approach, which can surface ethical conflicts and dilemmas, provides a good starting point for ethical discourse. Aroskar's case of Mrs. R, for example, concerns an elderly woman living, at her choice, in her own home, whose advancing Alzheimer's Disease is causing a decline in her competence and safety. The home health agency policy requires discontinuation of services when patient safety at home cannot be assured. The case pits individual autonomy against agency policy, and the patient's legal rights against professional responsibility to a patient (1998). The case explores in depth the competing ethical principles and theories. Because there is no "right answer" to Mrs. R's situation, Aroskar urges ethical reflection as the path by which an ethically responsible decision, or series of decisions, can be made. Yet the relationship between ethical decision making and professional responsibility to patients, agency policy, or law remains not especially clear. Silva's (1998) case of Jane, in the state health department, separates legal, ethical, and professional responsibilities, and analyzes political interventions taken by Jane to alter a physician's misappropriation of funds. Domains are more fully clarified, but not in depth.
To act as ethically-responsible professionals, nurses in practice, service, or academia need to distinguish what ethics is, is not, and how ethics fits with related domains such as morality, religion, agency policy, and law.
In an effort to facilitate ethical reflection in nursing, and to expand what it means to analyze ethical issues, this paper will succinctly map the deep origins of the domain of ethics 1, including: the history of the diversification of human societies and cultures, religious and philosophical traditions, commerce, the formation of nations, laws and government regulations, professional codes, communities, families and other socializing agents, local contexts, and organizations. Except insofar as the domain of morality has come to mean, in a generic sense, what is "right" and what is "wrong," an argument of this paper is that the domain of ethics must include, but ultimately be conceptualized as distinct from, morality. As will be noted shortly, one's morality is but one element prompting ethical conduct. Laws, professional ethical codes, government regulations, culture, and context further inform one's choice of action (see Figure 1).
Although this paper's grand scope may sound like it borders on the grandiose, I have endeavored to provide an inclusive overview that will not overwhelm my readers. My aim is to contribute to intelligent understanding, to the level of discourse within the profession and, ultimately, to provide nurses and their health care colleagues with a more coherent and penetrating understanding of the complex domain of ethical decisions. With discriminating judgment, nurse leaders are better equipped to craft ethically responsible decisions. Toward that end, a case study based on actual events is used to illustrate ethical complexity from an interdisciplinary administrative perspective.
Ethics literature for this article has been drawn from nursing, business, and health care writings. Because of the sheer number of definitions of ethics, I have made no attempt to cover comprehensively, or reconcile, the varying definitions of health care or administrative ethics; selections of related definitions from which the paper draws are illustrated below in Table 1.
Ethical standards emanate from many sources. A stream can be a useful image of the domain of ethics. Like a stream, ethics is dynamic and sometimes turbulent, the tributaries numerous. Both change shape to fit the varying contexts through which they flow:
- ethics has grown and changed over centuries as it formed within the landscapes of developing human communities;
- tributaries from many different cultural and historical sources have fed the stream;
- when one drinks from the stream of ethics at any given time, it is passing by a specific point and through a locale; and
- an individual selects the water to imbibe from the stream at that point in its journey.
The next section in this paper sketches in the foundation of ethics, thereby enabling readers to examine the sources of their own principles.
The Origins of Ethics
Ethics is linked to action. An ethical situation results in an individual making a choice among competing values. Metaphorically, the decision maker scoops selected cupfuls of water from the stream, and his/her choice will dictate action(s) to be taken. An ethical act -- a concrete decision within a specific situation -- flows from a mix of broad historical forces; the scope of those forces are out of reach of the ordinary person's conscious thought processes. In the following sections, I present those forces from a longitudinal perspective.
The first definition of ethic in the American Heritage Dictionary is "a principle of right or good conduct, or a body of such principles" (1983, 242).
Ethics is "a systematic process of reflection in which issues of what one morally ought to do are analyzed, decided, and evaluated through moral reasoning that encompasses, but is not limited to, ethical principles and theories" (Silva, 1990, 4).
"Ethics may be defined as the study of what is good or right for human beings. It asks what goals people ought to pursue and what actions they ought to perform. Business ethics ... studies the relationship of what is good and right for business" (Hoffman & Frederick, 1995, 1).
"Ethically justifiable behavior ... consists of morally correct decisions and actions in which the interests of the society take the degree of precedence that is 'right,' ... 'just,' and ... 'fair' over the interests of the individual. It is ... 'good' for society according to the ethical principles of normative philosophy, not according to the moral standards of a given group or culture" (Hosmer, 1995, 399).
Ethical work environments "are both multidimensional and multidetermined.... [T]here is variance in the ethical climate with organizations by position, tenure, and workgroup membership ... [and] significant differences ... both across and within firms" (Victor & Cullen, 1988, 101).
Organizational ethics is "'the intentional use of values to guide the decisions of a system'" (Potter, 1996, 4).
"For employees to engage in ethical reflection, Brown (1990) proposed that the conditions of power, trust, inclusion, role flexibility, and inquiry must be present. Workers should have the right to receive relevant information, to be free to say what is needed to be said about an issue (power), and to be free to disagree with one another in order to increase their understanding of issues (trust)" (Olson, 1998).
An "ethical decision is [one] that is both legal and morally acceptable to the larger community" (Jones, 1991, 367).
"[E]thics [is] a matter of daring to make the judgment [yourself] or of deferring personal judgment to the judgment of someone else" (Worthley, 1997, 156).
Survival and Early Societies
Starting from the most distant ancestral point, our stream of ethics originates in the survival strategies of early human communities (Table 2). Survival was tied directly to the geographic locale inhabited by the clan. Communities developed cultures which implicitly informed members "how to get along here," even while those cultures were transformed over time by new experiences (Diamond, 1999; Schein, 1985; Taft, 1997). From the very beginning, and in the form of prescriptive and proscriptive codes of behavior, ethics was part of the strategy of how to get along in this community. Additionally, spiritual beliefs provided guidance on phenomena that were beyond the rational and sensory explanations of the culture.
As the human population grew, migrated, and further diversified, cultural variation proliferated. The foundations of organized religion and philosophy emerged out of distinct environmental conditions, survival strategies, cultures, and societies. In Western cultures, the Judaic and Christian (Catholic and Protestant) religions prevailed, although not exclusively. Philosophical thought joined religious beliefs in the widening stream of ethics. Both religion and philosophy concerned themselves with what was right, wrong, fair, and just, what was "good" and how to find happiness, and the duties and obligations of human beings toward each other.
Beginnings of Human Life & Experience
Humans established close ties to the land & immediate environment. Cultures develop in small communities, of which ethics, rules, & spirituality were a part
Expansion of Human Population, Migration & Diversification
Enlargement & Dispersion of Human Communities
Formation of whole & separate societies
Proliferation of subcultures & diverse communities
Development of religions
Beginning of philosophical thought
Morality and values are the constructs most often included in definitions of ethics (see Table 1), and reasonably so. In America, morality and values derive largely from the religious and philosophical traditions of Western culture. Members of societies that are built on these traditions tend to agree on many fundamental principles, whether or not those members are themselves affiliated with a formal religion or even aware of their philosophical inheritance. For example, principles of fairness, charity, and kindness toward others are widely shared, as are prohibitions against theft, murder, lying, or reckless endangerment (Hosmer, 1995). Not all societies prohibit adultery or incest, although Western cultures do based on Judeo-Christian beliefs.
When one looks at the specifics of applying moral beliefs, however, even the seemingly more universal principles require qualification. For example, most individuals in the Western world would say that murder is wrong. But profound disagreement lurks just below the surface. What about euthanasia? war? abortion? slaughtering animals? or the failure to act that results in murder, such as societal inertia in failing to halt inner-city drug killings? Thus even the most uncontroversial of moral standards -- that murder is wrong -- yields to diverse opinion on practical issues and to a dynamic interplay in society of majority-minority views.
In antiquity, determinism vs. free will was debated by philosophers, as were hedonism and asceticism. Kantian philosophy provides us with such well-known precepts as the provision of reparations (righting wrongful acts done to us by others), showing gratitude toward others, and exercising one's duty toward self-improvement (Murphy, 1970; Silva, 1990). Utilitarian philosophy -- the greatest happiness (and the least pain) for the greatest number -- developed with Bentham and Mill (Smart, 1961). Karl Marx identified and condemned the engines of oppression in a class-based society (Tucker, 1969). More recently, Rawlsian theory examined justice related to the needs, duties, and resources of members of society (Rawls, 1971). Few nurses would be able to identify what Kant, Mill, Rawls, or Marx advocated, yet principles from their writings are strongly embedded in the value structure of professional nursing, thus tacitly influencing nurses' perceptions of ethical situations.
The Codification of Morality
Laws and government regulations, relatively recent developments of the industrialized world, are in essence the codification of morality (Table 3). A society holds certain values and beliefs and from these creates the laws that more formally govern human affairs. One finds echoes of the Ten Commandments, the Golden Rule 2, and lessons from the Old and New Testament throughout the legal systems of Western civilization (Hosmer, 1995). In the industrialized world, law and morality interlink extensively.
Often law establishes the minimum conduct expected from members of society and few, if any, positive duties (Darr, 1997) 3. In the U.S., democracy and democratic capitalism form the principled basis for our laws. The First Amendment to the Constitution demands that church and state (religion and law) are kept separate. We believe in the ideals of democracy which accord voice, vote, and basic human rights to every individual. The rights of an individual crime suspect, rather than those of the victim, are a priority in legal processes, sometimes to the perceived detriment of the larger society. One could argue that the utilitarian principle -- the greatest good for the greatest number -- is occasionally subverted by judgments in favor of the individual by the American legal system. In contrasting U.S. and Canadian public policy in the health care sector, the Canadian culture takes an egalitarian and utilitarian approach to governance as evidenced by an explicitly more fair and just distribution of public resources (Storch, 1988).
Religious & Philosophical Traditions
National Culture (U.S.)
National Laws & Regulations: The Societal Codification of Morality
U.S. law is the source of other practices common to health care. Judgment by one's peers -- what we in nursing call "peer review" -- originates in the jury system. The concept of due process, which is central to principles of objectivity, administrative fairness, and human resource management, comes to us from law. Government regulations of health care originate in legislation and are further developed and enforced by designated agents of the government. Legal protection for whistleblowers exists, but is limited to government-related employment (e.g. the VA System) and is generally not applicable to private organizations. Ethical conduct in the U.S. demands a level of individual consciousness that draws from but also extends beyond legal, moral, and philosophical imperatives. And as we shall see, there are additional social factors that influence ethical choicemaking.
In relation to ethics, laws are a commanding player because they derive from societal consensus about collective morality; hence one cannot separate ethical choice from legal principles. At this point in our discussion, however, it should also be clear that ethics cannot be distinctly separated from the related domains of culture, religion, philosophy, morality, values, government regulation, or commerce. Throughout evolution, ethics has flowed from yet additional norms governing human behavior.
The Capitalist Ethic
The capitalist ethic is a powerful template laid on all human affairs in the U.S. To bemoan the profit motive in health care, which nurses frequently do, is to portray oneself as idealistic and naive. Profit-generating activities have always been central to the provision of health care services in this country. Fortunes have been made in health care long before the emergence of private for-profit entities. What happens over time is simply that the key players who exert more control, and receive greater benefit, change -- not whether or not profits will be generated from health care services. In ethical situations associated with revenue generation, including the capitalist extreme of profiteering, the nurse needs to be cognizant of the boundaries between his/her personal values and what is legal and expected in American society. Moneyed interests drive organizations, and are fundamental and ubiquitous to the U.S. They must be knowingly factored into any analysis. Generating profit, by itself, is inherently ethically neutral. Ultimately the market decides who "deserves" to survive by where consumers put their money.
One must remember that the insured health care consumer selects health insurance based on a number of considerations, one of which is price. If a for-profit HMO can keep costs down and profits up by offering less choice and fewer services, the purchaser is often free to endorse or reject this approach by his/her choice of health plan 4. It remains incumbent on the purchaser to decide what s/he wants in a health plan and is willing to spend. Gradually, American purchasers are becoming more savvy about the costs and consequences of their health insurance choices.
Ethics within the Specific Context
An ethical decision always involves a specific situation within a local context (see Table 4). In a health care situation, this context would include, at the national level, the parameters of health care policy formulated through legislation. Those of us employed in the health care sector of the economy hold industry-based values (Gordon, 1991; Harrison, 1999) -- that is, a somewhat coherent framework of beliefs that interpret our work and place in society. During the 90's, for example, practitioners of all clinical specialties have tended to share a collective disdain for the negative effects of managed care on patient care. A related value shared by most health care workers is that, within the U.S., access to health services should be a basic human right.
Local/ State Governance, Culture, & Demographics
Commerce, Laws & Regulations
Local Communities, Families, & Other Socializing Agents
Standards of Professional Disciplines
Employing Organization & Context
Ethical Situation of Competing Values
Individual Decision & Action
Important occupational/disciplinary factors join the ethics stream as well. Professional standards of practice for nurses, established by the American Nurses Association and other professional associations, demarcate the boundaries of the discipline. Codes of ethics guide health care executives (American College of Healthcare Executives, and American College of Health Care Administrators codes), nurses (American Nurses Association), and physicians (American Medical Association), among others (Darr, 1997). Context would also include local and state laws or regulations, culture, and demographics. Context makes a difference. Advanced practice nurses, for example, face variations in state practice acts that govern what is, or is not, allowed within the scope of practice. If a nurse prescribed pharmaceuticals in a state not granting nurses prescriptive authority, his/her action would be considered both illegal and unethical. In heavily Mormon-populated Utah, a nurse counseling an unmarried, pregnant teenager might choose somewhat different sources of moral authority than s/he would select in counseling a teen from an impoverished section of urban Chicago. Context influences what we select as the "right" thing to do.
The local context would include the influence of gender (Gilligan, 1982; Kohlberg, 1981), and an individual's family and social network, which largely determine how one is socialized. Schools, churches, communities, treatment by friends and peers, and local leaders all contribute to the developing person's conception of right and wrong. The individual's level of maturity and moral development, courage to risk, and ego integrity affect his/her ability to act on principle.
Thus do tributaries in the form of local context enter the stream of ethics.
The Organizational Context
Importantly as a tributary of ethics, local context would also include the organization or setting in which an individual works. Managerial ethics assume a position of profound consequence here in the form of organizational policies and processes, culture, espoused vs. enacted values, leadership behavior, rewards and punishments, social networks, and treatment of employees (Argyris & Schon, 1974; Brass, Butterfield, & Skaggs, 1998; Chinn & Kramer, 1999; Johns, 1996; Kerr & Slocum, 1987; Rushton, 1995; Taft, Hawn, Barber, & Bidwell, 1999; Twining, 1987; Victor & Cullen, 1988; Weaver, Trevino, & Cochran, 1999; Wiener, 1988). Organizational policies and procedures dictate actions which may have ethical content (cf. Aroskar, 1998; Fletcher, Sorrell, & Silva, 1998). Organizational cultures create in employees a perception of the levels and limits of trust and integrity, two domains nearly synonymous with ethics (Becker, 1998; Chinn & Kramer, 1999; Covey, 1990; Fleming, 1996; Grover, 1993; Hosmer, 1995; Johns, 1996; Mayer, Davis, & Schoorman, 1995; Olson, 1998). Through organizational socialization, employees learn what constitutes acceptable behavior. The ethical conduct of leaders -- or lack thereof -- has a subtle but profound influence on the behaviors of all employees (Donaldson, 1996; Paine, 1994, 1997; Steward, 1996; Wilhelm, 1992).
Much of the literature on business ethics considers situations of relatively blatant and consequential misconduct, e.g. unsafe conditions for patients (e.g. Mohr & Mahon, 1996), retribution for whistleblowers (e.g. Fletcher et al., 1998; Near & Miceli, 1995), theft, sexual harassment (e.g. Wetlaufer, 1999), physical or emotional injury to others, conflict of interest, etc. In some cases, the organization may be dependent upon the wrongdoing 5. The most prevalent sources of ethical action, however, are the little everyday actions of managers which, though of no immediately visible consequence, build to create the ethical climate. There may be acts of commission or omission, or enactment of organizational standards that are inconsistent and place employees in a bind (Badzek, Mitchell, Marra, & Bower, 1998; Saffold, 1988).
To examine ethical behavior in management, one must bring into view the unavoidable and dynamic influence of money and power (e.g. Brosnan & Roper, 1997; Mayer et al. 1995; Worthley, 1997). Their influence can create a bias that, over time, may lead to what one would consider an unethical outcome. The following case scenario (see Table 5) is an illustration.
The Application of Ethics
When a situation is presented that calls for an ethical decision, the history of human cultures tacitly flows through the individual-in-context. As described in the preceding discussion, the stream is wide and deep from which a "cup" of ethics, or ethical choice, is drawn. Rarely is the individual faced with an ethical challenge conscious of the depth and breadth of the domain of ethics. Often the imperatives of the local context, e.g. organization, the force of law & regulations, the professional code of ethics, or Medicare billing rules, constitute the whole of the individual's conscious reasoning process. Time limitations are a constraint. Through individual critical, principled reasoning about the presenting situation, a decision is made and action taken.
If, however, the individual's ethical reflection takes account of the historical, cultural, and contextual elements of the situation, a more complex analysis can occur. In the case of Mrs. R. above, the elderly woman with Alzheimer's Disease who wishes to remain in her own home, other factors come into focus if the nurse more broadly thinks through the situation (Aroskar, 1998). Some of these broader factors would include:
In this community, there may be other borderline-competent elderly living at home. That is, if this type of situation is likely to re-occur, one must take into account not just Mrs. R. but also the generalized principles that the agency can apply to caring for other elderly/unsafe clients. Community and cultural demographics would play a role as well in how problems of this nature would be addressed.
Respect for autonomy is an important ethical principle but insufficient to resolve the situation. The nurse needs to understand local and state law on what constitutes mental competency, and to know the legal process required for assuming power of attorney.
It would be relevant to the nurse's thinking to understand the historical catalyst that led to agency policy on discharging incompetent patients living alone at home.
To resolve a conflict between agency policy (discontinue service to Mrs. R) and professional responsibility (beneficence, nonmaleficence, respect for autonomy), the well-grounded nurse would seek counsel and guidance from agency leaders.
On the basis of existing standards for professional conduct and out of respect for one's colleagues, the nurse should consider whether her coworkers would be comfortable with how she chooses to handle the situation. In addition to the potential for future effects on peers from the nurse's actions, colleagues are the appropriate players to judge each other by the standard of what a "reasonable nurse" would similarly do. The nurse would be well-advised to seek out peer input.
The nurse's personal moral stance in how the case should be handled is one factor among many. For example, perhaps this nurse has a commitment to values of altruism and individual rights that could influence her actions. Should her values be subordinated to the dictates of the law, the agency's policy vis-à-vis Mrs. R, the parameters of the Nurse Practice Act in her state, and the implications of her actions for the agency and other clients in the future? Probably yes.
It is sometimes easy to forget that one's professional choices and actions both reflect on and have consequences for one's professional peers. This area is part of comprehending one's immediate context in which an ethical situation arises. For example, if the nurse caring for Mrs. R. decided that, to get around agency rules, she would care for Mrs. R. at home on her own time, there could be potential effects on the agency and other nurses. What if something valuable was missing from Mrs. R's home after the nurse had visited? What if Mrs. R. were to injure herself at home? Start a fire? It is possible that the family could find the nurse negligent in not placing the patient in protective custody. And, there would be the potential for the family to bring suit against the agency because the nurse became involved with Mrs. R. through an agency referral. Negative publicity can affect agency referrals, caseloads, and perhaps cash flow and people's jobs. Alternatively, the nurse might get some positive publicity for her selfless care of Mrs. R. Then might other nurses be asked by their patients if they could provide similar off-duty assistance? If not, considering principles of justice and equality, why not?
Regarding the nurse's personal moral stance, it is always valuable for individuals to understand their own values, whether they derive from humanitarian, spiritual, or cultural beliefs. Morality is a particularly challenging element of ethics because morals are derived, directly or indirectly, from religious teachings, yet one's individual morals are personal and unique. Many nurses carry a humanitarian drive or sense of moral agency that underlies their choice of work in health care. Values associated with morals can cause the nurse to be biased in favor of a particular ethical action. When values are known at a conscious level, they serve to inform one's actions. When present but not consciously known, values influence one tacitly -- and potentially inappropriately.
In ethical decision making, one's individual morality is part of the whole analysis -- but alone, it should not be determinative. It is essential to know clearly the boundary between self and situation. This author disagrees strongly with several authors 6 who assert that the domain of ethics and morality are identical (Fletcher et al., 1998), and that ethics should prevail when laws are immoral (Badzek et al., 1998). In contrast, this author encourages health workers to incorporate laws, regulations, professional codes of conduct, cultural values, and mandates of the context into ethical reflection. In addition to morality, these elements inform the ethical choices that prompt action. To encourage obedience to morality as a higher order value system than law, government regulation, or agency policy, is deeply problematic. When a conflict exists and one acts on personal morality, the obvious and disturbing question is, whose morality prevails? Except insofar as morality refers generically to an individual sense of right and wrong, it is not a universal template. Nor is it neutral. Morality assumes its rightful place within a doctrine of relativism, not absolutism 7. One person's moral sanctions are another person's right to freedom and self-determination. While laws, regulations, or policies are based in part on moral beliefs and are hardly neutral themselves, they do strive to set societal and collective rules that are more inclusive of diverse beliefs than do individual forms of religiously- or philosophically-derived morality.
Worthley notes that "rules, like laws, serve best at regulating relationships between strangers or adversaries" (1997, 13). Personal values and nursing's professional values, e.g. caring, altruism, patient rights, equality (Silva, 1990), frequently merge together in the minds of nurses to strengthen personal ethical bias and, in some cases, prompt an incomplete ethical analysis. A nurse's sense of righteous disagreement can signal that this is happening. When it does, it is important to be clear about what one's personal moral preferences are, but to recognize that personal preferences should routinely yield to the primacy of law and, in most cases, of agency policy. In all but the most egregious cases of maleficence, or of an anticipated potential for harm (e.g. the case of Barry Adams in Fletcher et al., 1998), the nurse's duty is to adhere to the laws of the land regardless of personal beliefs.
To summarize the foregoing discussion, the complex origins of ethics are depicted in Figure 1.
Organizational Ethics Case Scenario
The following case (Table 5) illustrates a situation calling for ethical analysis by an OR nurse, and for subsequent review of the situation by hospital administrators. It is a composite of several actual malpractice cases.
John E., 10 years out of his undergraduate nursing program, worked as the OR circulating nurse in a large, inner-city, tertiary care Catholic medical center. He was part of the neurosurgery team, which included nurses with varying educational backgrounds, OR techs, a PA who scrubbed in, surgery residents, and various staff surgeons. John was raised in a nearby blue collar Italian neighborhood, and he still attended services at his old neighborhood church. He and his French girlfriend lived in a suburban high rise apartment complex overlooking a lake.
St. Anthony's Medical Center had served all classes of patients for over 100 years, but their location among the inner city poor seemed increasingly to discourage suburbanites from electing to receive care there. Nonetheless, the hospital had Church commitment and support and intended to remain, with renovations, in its current location, devoted to it altruistic mission. There were still nuns and priests in evidence as part of the staff.
For the past several years, John and his coworkers had observed that one of the neurosurgeons, Dr. X, seemed to be gradually losing manual dexterity in performing his surgical procedures. He was increasingly awkward with instruments. Sometimes his hands shook slightly. He had twice inadvertently burned patients with cauteries, although neither resulted in serious harm. The nurses and techs had discussed their observations among themselves, and had even approached the surgeon's PA with concerns. The PA had acknowledged an alteration in dexterity but indicated that he didn't see the changes as being anything dangerous. John had talked informally to the administrative head of the OR, a nurse manager, and to his nursing director. Both managers requested that staff put their concerns in writing. One of the team nurses had approached the Chief of Neurosurgery, who indicated that he would pay special attention to the quality reviews of Dr. X's OR reports. A tech, talking informally about her concerns with one of Dr. X's partners, was told that "only a surgeon can evaluate the surgical skills of another surgeon." The OR staff were reluctant to put any of their concerns in writing because they feared retribution by other staff surgeons as well as Dr. X. And it was true that they couldn't act as Dr. X's peer reviewer. It seemed to be generally "known" by a number of people working around the neuro team that Dr. X. was "showing his age." Yet he maintained an active surgery schedule.
Within a year, Dr. X. had an instrument "accident" in the OR in which he inadvertently severed nerves to a section of the brain of a 44-year old woman. Post-operatively, the woman evidenced extensive damage to reasoning and cognitive functioning and suffered from emotional lability. The patient was unable to return to work, and in fact became dependent upon her family for support and supervision. Dr. X. noted in his records that the woman's cerebral anatomy was somewhat anomalous and that several nerve pathways were located in an unusual area. The surgical damage was explained in the chart as an unfortunate and infrequent, but known, surgical risk for the type of operation she had undergone. Subsequent hospital chart reviews did not result in any action, either by the neurosurgeons or the hospital administration. On the basis of a confidential comment by Dr. X's scrub nurse, and from informal staff discussion, John E. suspected a "white-washing" of the facts. He decided to talk it over further with his OR manager.
Prior to Dr. X's accident, did management conduct themselves in an ethically prudent manner? Are management acts of omission here ethically relevant? An outsider reading this case, for example, might wonder if the hospital administration should have taken action before the serious accident occurred. Should the burden of evidence have rested on OR staff alone? Did the traditionally male Catholic Church hierarchy tend to reinforce a doctor-dominant status position within the hospital? If so, obedience to authority and respect for physician autonomy might be normative for such a culture. Or, stated differently, non-physician concerns raised about surgeons may not be deemed "credible" in a doctor-dominant institution.
John E.'s upbringing and values led him to feel strongly that it was wrong not to be honest with the patient's family. In his view, the hospital was morally obligated to contribute to the patient's maintenance as a semi-invalid. Would John E. have an ethical obligation to share what he perceived as hospital negligence with the patient's family? What about John's coworkers, who shared his views of fault and causality but were reluctant to come forward about institutional responsibility? Significantly, do staff bear any ethical responsibility for Dr. X's future patients (cf. Smith, Hiatt, & Berwick, 1999)?
In this author's view, the case of John E. & Dr. X. illustrates the power of individual ethical beliefs confronting organizational culture, managerial ethics, and state law. John and his coworkers have no legal right to bring the conduct of a physician under external scrutiny. Nor are they legally bound to come forward if they have additional information that might be valuable to an investigation. If questioned under legal proceedings, however, they have a legal, ethical, and (likely) moral obligation to tell the truth. The medical center does not require any input from John about his views. We know that he is ethically uncomfortable with the situation because, on the basis of information he has, he has formed his own conclusions that are at variance with the hospital's official position. Yet his ethical beliefs are John's only legitimate source of further action. If he did nothing more about the case, he would be within the rights and responsibilities of his role.
The medical staff members are key players in this situation. Indeed, this author would argue that inquiry and leadership should rightly come from them. Has any peer talked searchingly with Dr. X. about what went wrong in the procedure? To what extent will the physician staff members on the surgical quality review committee use this case to make further inquiry about Dr. X? Dr. X's partner knows about staff concerns; does he choose to act himself, or raise questions that the quality committee might pursue? What is the ethical duty of the Chief of Neurosurgery, or of Surgery? Is there any plan for another surgeon to monitor Dr. X. in the OR?
The real battleground for the ethical analysis of this problem lies within the medical center's administrative processes, and specifically within the hands of the leadership. If John E. has strong beliefs that the case should not be left as it is, his avenue for redress is through the institution. John E.'s manager was to hear his concerns, but what happens then is an issue of management and leadership ethics. If there is validity to John's observations and suspicions, questions should be raised via John's manager to organizational and surgical (physician) leaders. What is the likelihood that John E.'s manager will take the case proactively forward to his boss with the expectation that hospital leaders: a.) need to be aware of what might have caused patient injury, b) will be ethically motivated to address the organizational mechanisms that led to the accident, c) will prompt action by the medical staff, and d) if cause and effect justify, will discuss the situation openly with the family? How would JCAHO policy suggest that the hospital deal with the situation? Through organizational processes, there are inquiries that the management and leadership of the medical center can pursue regarding the case in an effort to determine what did happen and, if Dr. X. is found to be losing competence, what steps can be taken to prevent future patient injury. The failure of administrators to act in a situation of this type may constitute a failure of ethical administrative conduct.
Whatever path might be selected, there is no straightforward action clearly visible. In administrative action, conflicting obligations are the rule, not the exception (David, 1999; Davis et al., 1997; Worthley, 1997). Because they are less tangible and visible than most bioethical situations, administrative ethics will often affect choices in indirect or invisible ways.
Unfortunately, the barriers to full ethical follow-up by management in health care organizations are all too familiar to most nurses (cf. Ahern, 1996; David, 1999; Rushton, 1995; Uzych, 1996). Resistance to carrying the inquiry forward would be likely from many quarters. Barriers are presented in administrative realities such as: the presence of multiple competing value systems (Taft, 1987; Taft et al., 1999); fiduciary duty to the institution; the historical and present economic power of physicians, especially surgeons; the tendency for physicians to protect their peers (fidelity); the rights of Dr. X under state regulation, including a process for individual procedural justice; the sanctions discouraging a nurse from questioning medical practice; the protection of confidential patient information; managers' reluctance to stick their necks out for a case that is, vis-à-vis negligence, speculative; fear of information getting out that might lead the family to sue; and finally, administrative inertia. One organizational ethics researcher properly proposes that the history of conflict and segmentation between functional work groups should be studied as it influences ethical and unethical behavior (Gatewood & Carroll, 1991; Kahn, 1990). Nowhere is this consideration more pressing than in health care.
Jones (1991) notes that the level of moral intensity 8 is an important determinant of ethical behavior. In Dr. X's case, social consensus among administrative and physician leaders about the highest values to be served may be limited, and proximity to harm and the level of potential consequence difficult to predict. Such conditions would fuel administrative resistance to action. While nurses might reach a ready consensus that the safety of future patients was paramount, it is likely that health care managers, immersed in the daily realities of the power structure, would be slow to take decisive action. For John E. to pursue the case, either his and/or the OR manager's moral agency would need to be remarkably strong, or the hospital culture would need to be truly committed to quality improvement that encompassed all personnel 9. If the latter were in place, it would need to include a "non-blaming" ethos and an absence of retribution toward John E. (cf. Fletcher et al., 1998).
For professionals, ethical consciousness extends beyond the questions of the immediate situation into anticipatory ethics10. Fully responsible behavior by professionals requires trustworthy conduct, including the fulfillment of role responsibilities for responsiveness to patients, competence, accountability, prudence, probity, and leadership (Worthley, 1997). For the professional health care workers and managers at Dr. X's medical center, to know a physician may endanger patients at some time in the future is to demand that anticipatory ethics -- acting to avert a future harm -- be practiced.
Whichever actions are taken in this case, John will do well to be clear about the facts, and to take time to know what his legal, organizational, and professional roles allow and where his individual morals and ethics stand in contrast. Because ethical values are personal and open to interpretation, to lead with them involves greater risk than would following the law, or interpreting regulations, or following agency policy. This author does not advocate that nurses should always lead with their personal ethical beliefs. The dictates of law are usually the highest authority, but a thoughtful appraisal of a situation such as this may conclude that, from an ethical perspective, agency policy or interdepartmental politics were wrongly raised to a position of priority. In cases of clear and imminent harm to patients, professional ethical principles would then rightfully move to the forefront.
Regardless of what choices are made in this case, ethical reflection requires that the nurse understand the range of relevant principles flowing into his/her analysis. This author believes that John E. should, in this case, act on his individual ethical principles by pursuing appropriate responses from the hospital chain of command. He must understand, however, the limited support he is likely to receive from state law and regulations, and from hospital administrators who, in most agencies, are reluctant to challenge medical authority. John E.'s position is risky. With discriminating understanding of the ethical context, however, John E.'s actions can be carried to the limits of the power and influence of his role. Thereafter, the administrative ethics of leaders -- or lack thereof -- prevail.
Guidelines for Decision Making in Complex Ethical Situations
How then should nursing and health care leaders conduct discourse on the domain of ethics? The author proposes the following guidelines:
- Consciously acknowledge the separate but related domains of philosophy, religion, economics, law and government regulation, culture, industry and disciplinary effects, and individual context as they contribute to ethical decision and action.
- Understand that conflicting obligations are the rule, not the exception. In any presenting situation, differentiate one's personal from societal values.
- Identify the ethical value hierarchy of authority that should prevail. Unless a compelling likelihood of immediate or future harm to others is present, the principles of law, government regulation, and explicit organizational policy should rule -- in that order.
- When a compelling likelihood of harm to others does exist that is insufficiently addressed by law, regulation, or organizational policy, identify and discuss the ethical situation with trusted peers and managers. Consider both present and future scenarios, and acts both of commission and omission.
- Identify the process and people to engage in addressing the ethical challenge. Marshall peer support and initiate action.
- Understand the contingencies of the situation, including inherent risks for you, the nurse. Know what risks you can assume and what actions you personally are prepared to take as the situation moves toward a valid, or flawed, resolution.
From John E.'s perspective on ethical principles, the case involving him and Dr. X. had a low probability of being resolved to his satisfaction because nonparallel power bases were working against it. This might leave him unsatisfied and conflicted, and perhaps morally compromised enough to consider leaving his employer. On the other hand, a clear understanding of the historical, cultural, professional, and contextual factors of this case would lead him to realize that a different outcome would be equally unlikely in other employment settings. Health care organizations have entrenched status hierarchies that rarely yield to the primacy of a single nurse's voice (cf. American Nurses Association, 2000).
John E.'s opportunity to carry forward on his professional responsibilities to St. Anthony's patients had not necessarily been obliterated -- just attenuated. Future patients of Dr. X. might still be protected were John to remain in his position, assume a vigilant stance, keep the situation "alive" through observation and continued conversations with selected peers and supervisors11, and be prepared to act. From the perspective of anticipatory ethics, one could argue that it would be unethical of John E. to leave St. Anthony's. He was uniquely and singularly positioned, by virtue of his role, experience, and ethical distress, to help avert future maleficence. While ethical action by John was likely to be unsupported in this case, ethical deportment and future acts of beneficence remained viable.
Brown notes that engaging in ethical reflection requires a work environment marked by honesty, open inquiry, empowerment, role flexibility, and trust (1990). How many practicing nurses would say those characteristics are actively present for them in their organizations? John E.'s situation illustrates the politically sensitive nature of ethics when power and money are implicit players. This author calls on nurse leaders to do all they can to establish work environments where honesty and trust thrive.
Because nurses are so often in the middle of complex and important human experiences, some tragic and disturbing, and because they may know things that are protected from disclosure by sanctions, nurses need to understand ethics from a deep, well-grounded, and balanced perspective. Situations involving administrative ethics, as illustrated by the case of Nurse John E., are particularly complex and challenging for the nurse. Power and money are omnipresent influences for which strong ethical leadership is the only mediator. The presence of trust and honesty in the workplace, unpunished, signify a positive potential for right to prevail.
This article set out to support ethical reflection in nursing by exploring the domain of ethics, from whence it came, and how ethics is distinguished from related domains of religion, philosophy, culture, law, and context. A case situation based on real events illustrates the ethical conflicts inherent to health care administration. It is my hope that these ideas contribute to nurses' ability to support themselves and their patients through the inevitable occurrences of ethically difficult circumstances.
Susan H. Taft, PhD, MSN, RN
Susan Taft, PhD, MSN, RN is an Associate Professor of Nursing and adjunct Associate Professor of Administrative Sciences. She is Director of the MSN-MBA/MPA Dual Degree Programs at Kent State University. Her academic and consulting interests concern organizational behavior in service-based organizations, particularly health care systems. Dr. Taft serves on local health system boards in Northeast Ohio and has extensively studied administrative and executive conduct.
1 This article's focus is limited to Western cultural ethics. While Eastern traditions may fit the article's conception as well, the author's limited experience on Eastern terrain demands bounded generalization.
2 Some variation of the Golden Rule is found in most cultures around the world, it being one of the most universal and common of human values.
3 An exception would be Good Samaritan laws mandating assistance.
4 In situations where employees do not have choice among varying health plans, ethical questions should be raised about the employer's benefit plan. Health plans being offered can become an issue for collective bargaining, and for attracting and retaining good employees.
5 In the recent case of Columbia-HCA, one might hypothesize that the institution -- wittingly or unwittingly -- slid into a state of dependence upon the practice of billing fraud and abuse.
6 Authors cited are from this OJIN issue's topic on administrative ethics.
7 This assertion is largely in opposition to classical deontological theory which advances an absolutist stance about right and wrong.
8 Jones proposes that moral intensity is comprised of 6 characteristics: the magnitude of consequences, social consensus, probability of effect, concentration of effect, temporal immediacy, and proximity.
9 It is customary for physicians in hospitals to have different, separate, and confidential quality reviews, in contrast to all other categories of health workers.
10 Aroskar (1998) terms this preventive ethics.
11 One researcher advocates conversation and dialogue in the workplace as means to create a living theory of ethical behavior (Gatewood & Carroll, 1991).
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© 2000 Online Journal of Issues in Nursing
Article published November 8, 2000
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