Can Morality Exist in Health Care Management?

Kelsey French MNO 3375 M-4 12/4/12

The Ethical Considerations of a Hospital Administrator

I. The Ethical Issues of Hospital Administrators In every business, upper management has the critical role of making decisions for the company. However, what happens when these business managers are making

decisions that effect peoples health and survival. While the area of Medical ethics has always been a popular topic including extensive discussions of cloning, human stem cells and organ donations, the area of ethics in healthcare management is sparsely discussed. However, these management decisions made in the arena of hospital care are filled with ethical questions that have enormous impact on patients, staff and the served community. Hospital administrators face ethical questions with every managerial issue from allocating funds to departments, deciding what clinical services to offer, and how to assure a high quality of services. Trying to balance good patient care, while maintaining a successful business are elements that frequently result in placing ones ethical and moral principals into question.

The ethical community has long ignored this particular area of ethics due to the logic that decisions made by medical management are unlikely to harm patients, unlike mistake made by direct medical staff.1 However, ethical decisions made by hospital management create an environment and the pre-condition for hospital staff to integrate ethical practices into their daily work that directly affect patients.

Weber , Leonard . "Health Care Management Ethics: Business Ethics with a Difference." Business Ethics Quarterly 10 .4 (2000): 975-982.

3 In Healthcare management, there are three main areas of ethical concern: the responsibility of health care institutions for their patients, organizational issues within the hospital, and the community role of health care providers. First, hospitals have a

responsibility to their patients to get them the best care, give continuity of healthcare as well as create systems for doctors to give patients various possible treatment alternatives to improve the quality of care. Second, hospital administration must determine how to allocate resources utilizing policies and procedures that dont conflict with the professional or ethical codes of doctors or nurses. Lastly, management must consider their surrounding community, because in a public hospital, the community provides the funding, therefore, the hospital has a responsibility to provide a fair and effective system in which to deliver healthcare .2

Hospital administration has an obligation to a multitude of stakeholder groups that includes the staff, the surrounding community, and the patients. Patients represent a very unique group of stakeholders because during their time under the hospital administrators power, they are debilitated and dependent. Therefore, a special focus needs to be placed on this particular stakeholder group. With many different stakeholders with varying interests, a level of complication is added to a Hospital Administrators work to try and balance each stakeholders needs and desires.

Biller-Andorno, N., C. Lenk, and J Leititis. "Ethics, EBM, and hospital management." Symposium on Evidenced Based Medicine. N .p., n .d. Web. 20 Nov. 2012. <www .ncbi .nlm .nih .gov/pmc/articles/PMC1733819/pdf/v030p00136 .pdf> .

4 In the past fifteen years, hospitals have faced a significant change, from an entity meant to serve the public to an entity that is profit-centered. This change is dangerous for the health of patients as hospitals attempt to find ways to cut costs in order to increase profits. Hospital Administrators are forced to consider a balance between how to run a successful business and act virtuous.3 These two elements are very contradictory in the area of medicine. Patient care increases typically require additional spending that cut into hospital profits.

This clearly brings up what should be one of a Hospital Administrators biggest areas of ethical focus, the duty of care they owe to their patients. The cheapest way and the most cost-effective way to care for patients the majority of the time is not the best way to care for a patients needs. Additionally, during healthcare, psychological comfort can be equally important if not more important as a physical remedy, therefore, how much hospital efficiency should be sacrificed to help increase the comfort level of the patient. The extreme version of this situation involves the extremely ill and terminal patients. This group of patients has the most medical needs as well as psychological needs. Clearly, this presents a problem that could completely de-rail all hospital efficiency, as these patients require immense amounts of attention and resources. While normal businesses utilize cost-benefit analysis to determine what course of action to take, it is virtually impossible to utilize this process in a situation where you cannot ethically place a dollar amount on peoples feelings and emotions.

Rodwin, Marc A. . "Physicians' Conflicts of Interest HMOs and Hospitals." Medicine, money, and morals: physicians' conflicts of interest . New York: Oxford University Press, 199. 197-227.

5 Despite previous thought, Hospital Administrators are on the forefront of a multitude of ethical quandaries. While medical management faces all of the above issues, and many more, one of the largest ethical issues that Hospital Administrators face is how to allocate a limited amount of resources for competing purposes. Whether the resources are medical equipment, hospital personnel, or simply funds, all hospital departments are competing for the same pool of resources. Therefore, it is the critical role of Hospital Administrators to ethically determine a method in which to distribute these sparse resources to ensure that all patients have access to the necessary services they need and deserve.

To compound a Hospital Administrators ethical issues, it must be mentioned that Government Regulations place an additional strain on Hospital Administrators during resource allocation. Medicine is one business that is subject to an uncharacteristically large number of government regulations. Not only are hospitals subject to federal regulation but also, state and local regulation. Hospitals are regulated by over 30 regulatory agencies at the current time.4 Regulatory agencies have the power to create and enforce rules that are important to maintain and guarantee patient safety. However, these regulations cause enormous issues in the medical field. It has been estimated that for every hour of patient care, regulations require about forty minutes of paperwork.5 This violates not only one of the most important functions of a hospital, efficiency, but it places a large strain on resources that Hospital Administration must handle. One of the largest resources that

AMA. "Patients or Paperwork." The Regulatory Burden Facing America's Hospitals. American Hospital Association. 29 Nov. 2012. 5 AMA

6 Hospital Administrations struggle to allocate is personnel. paperwork makes personnel unavailable to help patients. Therefore, this added

Surprisingly, this particular area of ethical concern has been the focus of limited previous research. This is most likely because it was previously believed that all medical ethical decisions were made by Doctors, who are supplied with an immense amount of ethical training and Codes of Ethics to utilize as guidelines. Many believed that Hospital Administrators functioned by the same ethical guidelines that any managers do, and while this is somewhat true, they are faced with ethical issues that greatly extend past what normal managers must deal with.6 Due to the imperative nature of creating some form of Healthcare Management ethics, The American Hospital Association (AHA) issued guidelines in the ethical conduct for health care institutions to help them create a framework in which to consider ethical issues.

As many professionals in the medical field are realizing the importance and potential area of growth in the arena of Hospital Administrator Ethics, literature and meetings surrounding Administrator ethics are flourishing. Hospital Administrators are faced with extensive ethical issues including those previously discussed and many more such as promoting unrealistic expectations, failing to acknowledge mistakes, rationalizing incompetent behavior, and many more. For this reason, it would be very beneficial for Hospital Administrators to create a systematic approach in which to solve ethical dilemmas of any origin.
6

"Hospital Ethics Handbook." University of Kansas Medical Center . N .p , n .d 4 Dec . 2012. <http://www .kumc .edu/hospital/ethics/ethics .htm> .

II.

Possibilities to Resolve the Ethical Issue Everyday, hospital administrations make fundamental moral choices disguised as

administrative decisions or technical choices. While a great solution would be to consider each case individually utilizing an ethics committee, this is impractical in a hospital setting. Therefore, some system must be developed to help make non-arbitrary decisions that are based on a set of moral principles and values.

Aside from impractical solutions there are some possible courses of action that could potentially help resolve the issue of solving Hospital Administrator ethical issues. First, would be the possible to use of Hospital Ethics Committees to make administrators ethical decisions. Second, could be the application of the utilitarianism principal to make ethical decisions based on helping the majority of people. This utilitarianism concept could be paired with a more recent creation of Evidenced Based Medicine to determine which patients should be cared for. The third potential solution is to rank patient priority by department and make ethical decisions according to ranking. A fourth solution could be to use the ethical principles of justice and fairness to create a system to provide equal distribution of resources to all patients.

III.

Evaluate all Potential Options Historically, Hospital Ethics Committees have overseen hospitals ethical issues.

These committees have a variety of roles including: helping hospital administration staff to

8 implement clinical ethics, assistance in the creation of policies regarding medical ethics, and analyzing ethical questions that arise in the care of individual patients such as those with diminished capacity. However, it is evident based on the above information that the main focus of these ethics committees is clinical ethics, with little to no focus on the impact that administrator ethics has on the functioning of the entire hospital.7 Typically ethics committees are made up of a multi-disciplinary group of members that include nonphysicians such as lawyers, Board Members, CEO, Chief of Medical Staff and medical members such as doctors and nurses.8 This wide variety of opinions and perspective make this the perfect setting in which to resolve potential ethical issues in both the clinical and managerial hospital setting. However, by having the Hospital Ethics Committee evaluate and decide on managements ethical decisions, the hospital would lose efficiency, a critical element of a hospitals functioning. Additionally, by employing the Ethics Committee there would be no systematic method to simplify the process, and hospitals proper functioning would rely on a single board of people. This could place the patient stakeholders at risk for not getting the most immediate responses to ethical issues.

One of the most immediate solutions that might be sufficiently utilized in determining how to allocate resources, is the Theory of Utilitarianism. Utilitarianism focuses on the idea that the proper course of action is the one that maximizes the benefit for the maximum amount of people. This can translate into a medical quandary such as: should a hospital focus on preventative care, which benefits lots of people, or should the hospital focus on crisis/exotic treatments, which help less people but can be viewed as
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Lebeer, Guy. Ethical function in hospital ethics committees Leeber

9 directly saving at-risk lives. This exemplifies one of the largest paradoxes in healthcare.9 People in the minority of the healthcare system are typically the most desperate, therefore, by utilizing the utilitarian calculation, the minority will lose. This system would clearly leave many without care, a clear violation of the American Medical Associations Code of Medical Ethics.

Recently, many hospitals have begun to create innovative ways in which to address ethical issues in the management arena. A more recent tool known as Evidenced Based Medicine (EBM) has been developed to help medical administrators make decisions regarding hospital management.10 EBM helps administrators determine proper allocation of resources by allocating funding for effective treatment care and cutting out therapies, or allocating less money to therapies with low effective rates. However, what they failed to include in this analysis was the information that those therapies with low effective rates were typically unsuccessful because they were being used to treat the very ill, which is clearly a high-risk group. While this may seem like a beneficial tool, it is clearly a faade for the same usage of the utilitarian principle.

Another potential solution to help resolve conflicts between obligations is to rank patient priorities. Many people argue that the highest obligation for all hospitals and

Rolland, Phillip. "Whistle Blowing in Healthcare: An Organizational Failure in Ethics and Leadership - ISPUB ." Internet Scientific Publications, LLC . . N .p ., n .d . Web. 4 Dec. 2012. <http://www .ispub .com/journal/the-internet-journal-of-law-healthcare-andethics/volume-6-number-1/whistle-blowing-in-healthcare-an-organizational-failure-inethics-and-leadership .html#sthash .uO3hN5Sk .dpbshttp://> . Weber, 977

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10 doctors is to care for the very ill people. 11 Therefore, this would leave it up to the Hospital Administrators to allocate the resources according to what areas of hospitals care for the most sick. These areas would mainly include the Emergency Medical Department.

However, if this logic was used to distribute resources, Primary Physicians would be obsolete as they focus on preventative care, which according to this system is unimportant and, therefore, would not get any resources.

As established earlier, in the setting of medicine, Utilitarianism is difficult to sustain. Peoples lives cannot be treated as a financial cost-benefit analysis. Rather, ethical

principals of justice and fairness should be the fundamental principals by which Hospital Administration makes ethical decisions. Just as it suggests, these principles are founded on the concept that all are treated the same. When it comes to medicine, one department cannot outrank another because if that is allowed, it creates a system and pattern of unfairness that will ultimately lead to less beneficial patient care.12 A system of making managerial ethical decisions with the principles of justice and fairness will not always result in the correct solutions, however, it will provide a solid groundwork from which decisions are influenced to help get the best possible solution.

Clearly, there is no perfect answer to this issue as there will always be a minority group who is overlooked during managerial planning and allocation. However, it should be

"Benefits Consensus Report." American Medical Association. N .p., n .d . Web. 4 Dec. 2012. <http://www .ama-assn .org/ama/pub/physician-resources/medical-ethics/the-ethicalforce-program/fair-health-care-coverage/benefits-consensus-report .page?> . 12 Buell, John. "Ethics and Leadership." Healthcare Executive June 2009:
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11 the goal of hospital management to minimize these issues and create fair treatment for all. Therefore, by creating a set of tools by which to make ethical choices, this will allow for some flexibility while maintaining a level of consistency.

IV.

Develop an Action Plan When trying to implement a new system of ethical considerations, the most

important first step is to create a foundation. In the case of Hospital Administration ethics, this foundation begins with each individual manager and their personal codes of ethics. If a person does not have a strong personal set of ethics, they cannot be expected to implement and execute a company-wide system of ethical decision-making.13

Each individual person has a personal code of ethics, however, in the field of Healthcare Administration it is critical for these managers to have a strong personal sense of ethics in order to make moral decisions that alter peoples lives. While, everyone will develop their own code in varying ways with a variety of different values, there is a general set of values that would be beneficial for healthcare managers to embrace to help them handle difficult ethical decisions.

The most important quality for hospital administrators is their ability to be fair. Fairness is crucial in order to provide care equally to patients needing treatment and not provide one patient with more care than the others. Transparency is key in medical

13

Baily, Mary Ann. "Healthcare Quality Improvement: Ethical and Regulatory Issues." The Hastings Center. 25 Nov. 2012.

12 management ethics as an open relationship with patients and co-workers allow for effective communication that can lead to better incorporating peoples opinions and ideas into hospital ethical codes.14 Respect would allow one to recognize that people have individual rights and that they are not simply items that can be manipulated. The ability to negotiate is critical as one in the position of a medical manager will be forced to deal with a variety of conflicting forces and competing claims and they need to be able to sensitively work will everyone to create balance.

In addition to the individual Hospital Administrators moral framework, it is important to consider the ethical situation of hospital employees to determine how they will react to new ethical procedures. Medical professionals, including doctors and nurses, must abide by very strict Professional Codes of Ethics. Not only do doctors take the Hippocratic oath, which provides guidelines for how to practice medicine in an ethical and honest way, but doctors are also subject to the Code of Ethics laid out by the American Medical Association.15 These, unlike the Hippocratic oath, contain extensive information for a wide array of potential medical ethics questions. Additionally, there is even an International Code of Ethics for physicians to follow so that doctors all around the world hold similar ethical values. Nurses also must follow a Code of Ethics From the American Nursing Association to help them navigate their profession.

Despite the fact that Doctors and Nurses both have very clear professional codes of ethics to follow, it is still imperative for these professionals to work and operate in an
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Baily Buell

13 environment that fosters good ethical behavior. Therefore, it is a crucial job of hospital

administration to create a Corporate Code of Ethics that applies not only to the professionals previously mentioned, but also to all hospital employees. If ethical behavior becomes part of an organizations value and culture, a Hospital Administrator will have created an ethical landscape that will naturally encourage employees to behave in ethical ways.

By creating a strong foundation of ethics as well as a company environment that encourages all ethical behavior, it will be more natural for a system in which to make all managerial ethical decisions to be accepted. The principles of the system to be

implemented are the ethical principles of justice and fairness, no priority or benefit should go to any singular group. While following this system will need to be slightly tailored for each particular situation, for the purpose of explanation, the example of allocation of resources will be used to explain each section.

The system is first and foremost participatory. By including representatives of all involved parties, it provides each the opportunity to explain outright what their needs are. In a hospital setting, each department is not going to need equal funding or resources, so by upfront determining the desires of each party, negotiations may follow. After compiling all facts and figures, assuming there is less available resources than have been requested, the system will proceed to the next step.

14 The following step requires historical data from each departments previous years allocation of resources and how much was actually used throughout the year. Utilizing multiple years of previous data, administrators will be able to determine if the requested amount is reasonable based on the actual performance and activities of a department. If any are commercially unreasonable they will be reduced to a reasonable level via negotiations with the department representative.

If a deficit in resources still exists, an equal cut across all departments will be made until the total amount requested matches the available amount. By equally cutting and not rewarding under or over utilization of resources, employees have no incentive to either do minimum care on patients or perform extraneous tests and procedures on them simply to use resources. Many times employees are rewarded if they do not use all their resources, and this encourages employees to cut corners when caring for patients, which is clearly unethical. Similarly, frequently employees will constantly over-request resources just so they can preform extraneous procedures in order to get additional pay. This practices is wasteful and additionally, unethical. This system protects against this to create a more fair and equal work environment.

This system can be applied in some form to all ethical issues that a Hospital Administrator will face. Step one is to figure out what the involved parties desire. Step two is to figure out if the request is reasonable based on prior experience with this issue. This is, of course, only a relevant step if there is prior data. If there is no prior data, the process should review the industry norm to determine how most people handle this situation. If

15 there is still no information, then perhaps some research and a specialized board can assist in a settlement. Step three levels out all requests equally either through equal cuts or negotiation with all parties. The key to this system is transparency, at anytime any member of an organization should be able to and is entitled to understanding every step of the process. This will ensure that the integrity of the system will be maintained, as a wide variety of people will constantly be monitoring the system.

In the delicate field of medical ethics, this important sub-set of Hospital Administrator Ethics creates the backbone for the entire inner-workings of a hospital. Systems such as the one created above help to maintain consistency among all ethical decisions and help to develop a strong moral culture within a hospital. Due to the high stress environment of a hospital, a cohesive culture is critically important. Just as in the Parable of the Sadhu, in order to determine the best course of action, there needs to be a set of mutually accepted group values. A hospital is no exception. When management is faced with difficult decisions, no matter what the situation, if they have both an ethical personal and ethical corporate framework along with a systematic method to solve ethical dilemmas, they will have all the tools necessary to enhance the hospital and place patient care first.

16 V. Bibliography

"Benefits Consensus Report." American Medical Association. N.p., n.d. Web. 4 Dec. 2012. <http://www.ama.org/ama/pub/physician-resources/medical-ethics/the-ethicalforce-program/fair-health-care-coverage/benefits-consensus-report.page? >. Biller-Andorno, N., C. Lenk, and J Leititis. "Ethics, EBM, and hospital management." Symposium on Evidenced Based Medicine. N .p., n .d. Web. 20 Nov. 2012. <www .ncbi .nlm .nih .gov/pmc/articles/PMC1733819/pdf/v030p00136.pdf>. Buell, John. "Ethics and Leadership." Healthcare Executive June 2009: Baily, Mary Ann. "Healthcare Quality Improvement: Ethical and Regulatory Issues." The Hastings Center. 25 Nov. 2012. "Hospital Ethics Handbook." University of Kansas Medical Center. N.p., n.d. Web. 4 Dec. 2012. <http://www.kumc.edu/hospital/ethics/ethics.htm>. Lebeer, Guy. Ethical function in hospital ethics committees AMA. "Patients or Paperwork." The Regulatory Burden Facing America's Hospitals American Hospital Association. 29 Nov. 2012. .

Rodwin, Marc A. "Physicians' Conflicts of Interest HMOs and Hospitals." Medicine, money, and morals: physicians' conflicts of interest. New York: Oxford University Press, 1993. 197-227. Rolland, Phillip. "Whistle Blowing in Healthcare: An Organizational Failure in Ethics and Leadership ISPUB." Internet Scientific Publications, LLC. N.p., n.d. Web. 4 Dec.2012.<http://www.ispup.com/journal/the-internet-journal-of-law-healthcareand-ethics/volume-6-number-1/whistle-blowing-in-healthcare-an-organizationalfailure-in-ethics-and-leadership .dpbshttp://> . Weber , Leonard . "Health Care Management Ethics: Business Ethics with a Difference." Business Ethics Quarterly 10 .4 (2000): 975-982.