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1
Ethics in Health
Assistance Organizations
Center of Studies of Applied Ethics
Faculty of Philosophy and Humanities
Universidad de Chile
Teodoro Wigodski
August, 2007
2
The Goals of Medicine
• Prevent diseases and promote health
• Alleviate pain and suffering caused by diseases
• Caring for and curing those who suffer from diseases,
along with caring for those who can not be cured
• Prevent premature death and facilitate a peaceful death
Source: The Goals of Medicine: The Forgotten Issues in Health Care Reform
(Hastings Center Studies in Ethics) by Mark J. Hanson.
Georgetown University Press; 2001
3
Sense of the medical profession
• Hippocratic Medicine:
– Lifestyle
– Service vocation
• Scientific-technical competences and values
– Fidelity to the trust of patients and society
– Compassion
– Prudence
– Justice
– Strength
– Moderation
– Integrity (intellectual honesty)
– Personal postponement
Source: 1) Hippocrates. 2) El sentido de las profesiones de la salud. Dr Juan Pablo Beca Infante
4
Considerations regarding health care
• Granting health to the population is not free. It
has an increasing cost and someone has to
assume it.
– State via Budget of the Nation (Taxes)
– Insurance System
• Health care models have to be sustainable:
technically and financially over time, to serve
future generations
Source: Ética de las organizaciones de salud. Dr Alejandro Goic G.
Rev Med Chile 2004; 132: 388-292
5
• Just as doctors and health professionals have
responsibilities towards their patients
• Healthcare organizations have responsibilities
towards their entire patient population as well as
other stakeholders:
– insurers, shareholders, business partners, payers, the
government and the public.
From the professional to the Institutional
6
From the professional to the Institutional
• That which can not be otherwise, is not a matter of
ethics (freedom).
• Ethics is the use of reason in the field of self-
determination, convictions, the strength of
conscience and its expression in civil society.
• Of what we can demand of each other.
• And for what?
– Ethics is the use of reason to live well, the best possible, to
optimize, for good practices.
• To choose well: deliberate, think.
– We need time to think and be able to do things better.
Source: "Ética y Responsabilidad Social de las Instituciones de Salud"
Jesús Conill Sancho. Specialist and professor of philosophy of the Universidad de Valencia, España
7
From the professional to the Institutional
• We want an excellent life.
• In order to have an excellent life, it is not enough
that people are excellent, but as we live more and
more in organizations, in institutions, we also need
institutions of excellence.
• What ethics are we going to be able to develop?
– Because we are historical, cultural animal beings and we
live in a certain moment of development,
– Ethics moves in a specific cultural and historical moment.
8
From the professional to the Institutional
• Ethics is not only personal, even though the focus
and end of all ethics is personal life.
• The notion of person is relational and those
relationships are open to institutions and
organizations.
• Most doctors and health professionals work in
hospitals, in institutions, when they have been one of
the traditional liberal professions of individual
exercise
9
From the professional to the Institutional
• Modern ethics is an ethic that moves in the
world of interests,
• There may be legitimate or illegitimate
interests, generalizable or non-
generalizable, consensual or not,
harmonizable or not, universal or not, etc.
• We must combine interests.
10
From the professional to the Institutional
• Ethics of responsibility means that even if you
have the convictions, it is not based only on
the convictions of yes or no, black or white.
• Life are possibilities.
• Therefore, responsibility means that life is
complex.
• And one of the preponderant features of our
time is that we are more aware and more
powerless in the face of complexity.
• The systems we have invented to reduce
complexity, so far what they have done is
increase it.
11
From the professional to the Institutional
• Because of the growing complexity we have to learn from
the consequences of our actions.
• The risks are sometimes unknown.
• That is why, in bioethics, the precautionary, calm principle
has been established, an expression of institutional
prudence.
12
From the professional to the Institutional
• The Health Institution is an invention of the 19th century.
• In the history of mankind, medicine has been a private
matter.
• It became a public matter in the hands of the State.
• This trajectory took a crucial step in the 1970s to focus on
health institutions, whether of a public, state, private or
mixed nature.
13
From the professional to the Institutional
• The new theories of justice, beyond ideologies,
philosophers such as John Rawls, gave a push to conceive
that health institutions have to be made from justice.
• They integrated: social liberalisms and liberal socialisms.
14
From the professional to the Institutional
• Health is a primary good that gives a positive right to
health care.
• The health institutions have had to assume a theory of
justice in which the demand for health care is inserted by
virtue of equal opportunities.
• The problem arises: with the generalization of health care,
in virtue of that equality of opportunities, a clash between
the demands of justice and the scarcity of resources begins
to take place.
15
From the professional to the Institutional
• There are new bioethical problems.
• Bioethics is not only what appears in the
front pages of newspapers, issues such as:
euthanasia, abortion, cloning, etc.
• The bioethics of the day to day, which is
not seen, is the financing and
management of health resources.
• The clash of the demands of justice and
the scarcity of resources, financing and
management.
16
From the professional to the Institutional
• Rationalizing costs, investments, health expenditures
tend to increase because the expectations of the
population increase.
• Combine efficiency and justice.
• Try to resolve business management issues, which
causes a lot of mistrust among health professionals.
17
From the professional to the Institutional
• The consequences of the
judicialization of medicine, lead the
doctor to spend the inadequate to
protect themselves.
• It is necessary to look for the
necessary incentives to promote, to
produce an excellent medicine.
• Not everything consists of reducing
spending, you have to know how to
spend and save.
18
From the professional to the Institutional
• Expand the horizon of professionalism: Social
Responsibility of the Institution.
– Creation of a School of Medicine together with the University.
• Social Responsibility must be at the core of the Institution,
in its strategic plan, keep in mind the stakeholders,
• Otherwise it would be a cosmetic and not an ethic.
19
• Healthcare Organizations and their administrators must
fulfill four main roles:
– Carer
– Employer
– Citizen and
– Administrator
FOUR PRINCIPLES OF ORGANIZATIONAL ETHICS
20
Context
At the center of health care there is an asymmetrical
relationship between:
• suppliers with skills and expert knowledge, and
• patients who are vulnerable, not only because they
are sick but also because they usually lack expert
knowledge,
and therefore depend on caregivers who act in their
interest.
1.- Provide Care with Compassion
21
• The nature of the patient-caregiver relationship
confers fiduciary duties to caregivers to promote
patient-centered values, such as competence,
compassion, trust and shared decision-making.
• In a Health Care Organization (HCO), professional
capacity is ensured by setting high standards,
promoting continuous professional development,
relating incentives: to the quality of care instead of
only to costs, and ensuring adequate staffing.
– Compassion and kindness are the appropriate responses to
suffering, and can be promoted by formal and informal rules
and rewards.
1.- Provide Care with Compassion
22
• Another fundamental component is that patients can
rely on the HCO and health professionals to provide
care tailored to their needs ahead of the interests of
third parties.
• One way in which HCO can be a reliable caregiver is to
allow those who care for them to be advocates for their
patients and help to: create, criticize and improve the
processes to provide well-being to patients.
1.- Provide Care with Compassion
23
Another element is shared decision making.
• patients and caregivers must decide on the treatment
as a whole through shared information,
• understanding the possibilities of each one, and
• following the principles of clinical ethics, especially
autonomy and beneficence.
1.- Provide Care with Compassion
24
• Therefore, within the role of care provider of a HCO
• the competition,
• compassion,
• trust and
• shared decision making
• They form the basis of a binding principle:
– provide compassionate care.
1.- Provide Care with …..
25
• While the role of the care provider is primarily
informed by clinical ethics, the remaining roles -
employer, care and manager - are based on the field
of business ethics.
• The duties of employers towards their employees are
related to the rights of workers and the trade union
movement.
• Kant's principle of "respect for people" is invoked to
argue that businesses should treat their employees
as ends in themselves, and not just as means to
increase productivity and profit.
2- Treat employees with respect
26
• The relationship between the employer and the
employee is one of reciprocal responsibility but with a
differential of power in favor of the employer.
• The duties of the employer include:
– the provision of fair remuneration,
– ensure safe working conditions, and
– reward and discipline fairly.
• This requires protecting employees from
discrimination and persecution in the workplace
• And allow to express opinions about politics in ethical
matters.
2- Treat employees with respect
27
• Organizations can and must empower their
employees to become responsible actors by creating
an ethical climate and serving the self-actualization of
their employees.
• Such empowerment is a prerequisite for employees
to take responsibility for their actions and not hide
behind rules and structures.
2- Treat employees with respect
28
CASE
A nurse has a wound caused by a hypodermic needle
when treating a high-risk patient, and the patient
refuses to be tested for HIV.
¿?
29
• If the patient is HIV positive, prophylactic treatment
can reduce the nurse's risk of HIV infection.
• If the patient is HIV negative, prophylactic treatment
offers no benefit, is costly, and exposes the nurse to
the collateral risks of gastrointestinal problems, bone
marrow suppression, and unnecessary stress.
Analysis of the case: Conflict between
Principle of compassionate care and
Principles of respectful treatment of employees
30
• Clinical ethics, with its focus on the patient's rights to
self-determination, can favor respect for the patient's
autonomous decision to refuse the HIV test.
• The nurse, however, also deserves respect, and the
Health Care Organization has a moral duty to its
employees to minimize health risks related to the
workplace.
• In this case, duty towards an employee may
outweigh the patient's right to refuse an HIV test.
Proposed solution
31
• Citizens' expectations regarding caregivers and
Health Care Organizations include:
– participation in a democratic society,
– the responsibilities that businesses generally have with
respect to society, and
– the special responsibilities that health care entails.
3.- Act with a public spirit
32
• The Health Assistance Organizations have
the duty to obey the Law.
• In return, they obtain benefits from the
obligations of the State regarding: service,
protection, respect for rights, and receptivity
towards citizens as consumers and
taxpayers.
• Some theorists of business ethics have
argued that, in return for granting companies
their legal status as independent entities,
Society has the right to expect from them a
positive net contribution to the general good.
3.- Act with a public spirit
33
• This is especially valid for businesses involved in
providing health care, because in a double sense, it is
a basic social good:
– First, the granting of health care and compassion
has intrinsic value that complements the social
dimension of humanity.
– Second, like food, education, and housing, health
care is a good that people need to thrive and get
the most out of their opportunities.
3.- Act with a public spirit
34
• Adequate health care is a prerequisite for the normal
functioning of modern society, therefore, businesses
that provide this type of good support special social
responsibilities, regardless of their profit-generating
status.
3.- Act with a public spirit
35
• It is expected that Healthcare Organizations can fulfill
their citizen role through;
– the proper disposal of hospital waste,
– provision of free services and outreach to those
who do not have access to care, and
– support in matters that are of interest to public
health.
3.- Act with a public spirit
36
• The principle of acting with a public spirit is also
relevant with respect to:
– the kinds of service that are provided,
– how to ensure access to them,
– how the actions of organizations and their
members are perceived, and
– how those actions can affect a broader
community.
3.- Act with a public spirit
37
Example
• The case of corporate social
responsibility occurred in 1982, when
several flasks of Tylenol were
sabotaged, resulting in seven deaths.
• The CEO of Johnson & Johnson was
frank with the press and the public,
removing all stocks from store shelves
at a cost of US $ 105 million, and
immediately ordered the development
of inviolable containers.
38
• The administrators of the Health Assistance
Organizations are in charge of promoting the success of
their institutions, within the availability of resources.
• The demands of the stakeholders must be prioritized
according to the purpose and mission of the
organization.
• Because the reason for an HAO is to take care of the
health of the patients, the basic obligation is defined by
the principle of caring with compassion and making
compatible with the generation of surpluses.
4.- Spend resources reasonably
39
• Market forces can induce dilemmas for the care
mission of a Healthcare Organizations, and their
managers must balance the sustainability and
financial performance of the organization with other
roles and responsibilities.
• Administrators face the task of setting ethical limits in
a deliberate, fair, and transparent manner.
4.- Spend resources reasonably
40
• The four principles of organizational ethics provide a
framework for discussing the moral obligation of
healthcare providers.
• The relative weight of each principle will depend on
the type of organization.
– In provider organizations, compassionate care will
be a priority, whereas in an insurance company,
acting in a public spirit can be of special
importance.
CONCLUSION
41
The Principles are sufficient?
• In addition, sufficient budget is required to
finance the operation and development of the
Health Assistance Organizations:
– State funds
– Private funds
• Donors
– Beneficiaries of the health system
– Health Insurance Companies

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Ethics in health assistance organizations

  • 1. 1 Ethics in Health Assistance Organizations Center of Studies of Applied Ethics Faculty of Philosophy and Humanities Universidad de Chile Teodoro Wigodski August, 2007
  • 2. 2 The Goals of Medicine • Prevent diseases and promote health • Alleviate pain and suffering caused by diseases • Caring for and curing those who suffer from diseases, along with caring for those who can not be cured • Prevent premature death and facilitate a peaceful death Source: The Goals of Medicine: The Forgotten Issues in Health Care Reform (Hastings Center Studies in Ethics) by Mark J. Hanson. Georgetown University Press; 2001
  • 3. 3 Sense of the medical profession • Hippocratic Medicine: – Lifestyle – Service vocation • Scientific-technical competences and values – Fidelity to the trust of patients and society – Compassion – Prudence – Justice – Strength – Moderation – Integrity (intellectual honesty) – Personal postponement Source: 1) Hippocrates. 2) El sentido de las profesiones de la salud. Dr Juan Pablo Beca Infante
  • 4. 4 Considerations regarding health care • Granting health to the population is not free. It has an increasing cost and someone has to assume it. – State via Budget of the Nation (Taxes) – Insurance System • Health care models have to be sustainable: technically and financially over time, to serve future generations Source: Ética de las organizaciones de salud. Dr Alejandro Goic G. Rev Med Chile 2004; 132: 388-292
  • 5. 5 • Just as doctors and health professionals have responsibilities towards their patients • Healthcare organizations have responsibilities towards their entire patient population as well as other stakeholders: – insurers, shareholders, business partners, payers, the government and the public. From the professional to the Institutional
  • 6. 6 From the professional to the Institutional • That which can not be otherwise, is not a matter of ethics (freedom). • Ethics is the use of reason in the field of self- determination, convictions, the strength of conscience and its expression in civil society. • Of what we can demand of each other. • And for what? – Ethics is the use of reason to live well, the best possible, to optimize, for good practices. • To choose well: deliberate, think. – We need time to think and be able to do things better. Source: "Ética y Responsabilidad Social de las Instituciones de Salud" Jesús Conill Sancho. Specialist and professor of philosophy of the Universidad de Valencia, España
  • 7. 7 From the professional to the Institutional • We want an excellent life. • In order to have an excellent life, it is not enough that people are excellent, but as we live more and more in organizations, in institutions, we also need institutions of excellence. • What ethics are we going to be able to develop? – Because we are historical, cultural animal beings and we live in a certain moment of development, – Ethics moves in a specific cultural and historical moment.
  • 8. 8 From the professional to the Institutional • Ethics is not only personal, even though the focus and end of all ethics is personal life. • The notion of person is relational and those relationships are open to institutions and organizations. • Most doctors and health professionals work in hospitals, in institutions, when they have been one of the traditional liberal professions of individual exercise
  • 9. 9 From the professional to the Institutional • Modern ethics is an ethic that moves in the world of interests, • There may be legitimate or illegitimate interests, generalizable or non- generalizable, consensual or not, harmonizable or not, universal or not, etc. • We must combine interests.
  • 10. 10 From the professional to the Institutional • Ethics of responsibility means that even if you have the convictions, it is not based only on the convictions of yes or no, black or white. • Life are possibilities. • Therefore, responsibility means that life is complex. • And one of the preponderant features of our time is that we are more aware and more powerless in the face of complexity. • The systems we have invented to reduce complexity, so far what they have done is increase it.
  • 11. 11 From the professional to the Institutional • Because of the growing complexity we have to learn from the consequences of our actions. • The risks are sometimes unknown. • That is why, in bioethics, the precautionary, calm principle has been established, an expression of institutional prudence.
  • 12. 12 From the professional to the Institutional • The Health Institution is an invention of the 19th century. • In the history of mankind, medicine has been a private matter. • It became a public matter in the hands of the State. • This trajectory took a crucial step in the 1970s to focus on health institutions, whether of a public, state, private or mixed nature.
  • 13. 13 From the professional to the Institutional • The new theories of justice, beyond ideologies, philosophers such as John Rawls, gave a push to conceive that health institutions have to be made from justice. • They integrated: social liberalisms and liberal socialisms.
  • 14. 14 From the professional to the Institutional • Health is a primary good that gives a positive right to health care. • The health institutions have had to assume a theory of justice in which the demand for health care is inserted by virtue of equal opportunities. • The problem arises: with the generalization of health care, in virtue of that equality of opportunities, a clash between the demands of justice and the scarcity of resources begins to take place.
  • 15. 15 From the professional to the Institutional • There are new bioethical problems. • Bioethics is not only what appears in the front pages of newspapers, issues such as: euthanasia, abortion, cloning, etc. • The bioethics of the day to day, which is not seen, is the financing and management of health resources. • The clash of the demands of justice and the scarcity of resources, financing and management.
  • 16. 16 From the professional to the Institutional • Rationalizing costs, investments, health expenditures tend to increase because the expectations of the population increase. • Combine efficiency and justice. • Try to resolve business management issues, which causes a lot of mistrust among health professionals.
  • 17. 17 From the professional to the Institutional • The consequences of the judicialization of medicine, lead the doctor to spend the inadequate to protect themselves. • It is necessary to look for the necessary incentives to promote, to produce an excellent medicine. • Not everything consists of reducing spending, you have to know how to spend and save.
  • 18. 18 From the professional to the Institutional • Expand the horizon of professionalism: Social Responsibility of the Institution. – Creation of a School of Medicine together with the University. • Social Responsibility must be at the core of the Institution, in its strategic plan, keep in mind the stakeholders, • Otherwise it would be a cosmetic and not an ethic.
  • 19. 19 • Healthcare Organizations and their administrators must fulfill four main roles: – Carer – Employer – Citizen and – Administrator FOUR PRINCIPLES OF ORGANIZATIONAL ETHICS
  • 20. 20 Context At the center of health care there is an asymmetrical relationship between: • suppliers with skills and expert knowledge, and • patients who are vulnerable, not only because they are sick but also because they usually lack expert knowledge, and therefore depend on caregivers who act in their interest. 1.- Provide Care with Compassion
  • 21. 21 • The nature of the patient-caregiver relationship confers fiduciary duties to caregivers to promote patient-centered values, such as competence, compassion, trust and shared decision-making. • In a Health Care Organization (HCO), professional capacity is ensured by setting high standards, promoting continuous professional development, relating incentives: to the quality of care instead of only to costs, and ensuring adequate staffing. – Compassion and kindness are the appropriate responses to suffering, and can be promoted by formal and informal rules and rewards. 1.- Provide Care with Compassion
  • 22. 22 • Another fundamental component is that patients can rely on the HCO and health professionals to provide care tailored to their needs ahead of the interests of third parties. • One way in which HCO can be a reliable caregiver is to allow those who care for them to be advocates for their patients and help to: create, criticize and improve the processes to provide well-being to patients. 1.- Provide Care with Compassion
  • 23. 23 Another element is shared decision making. • patients and caregivers must decide on the treatment as a whole through shared information, • understanding the possibilities of each one, and • following the principles of clinical ethics, especially autonomy and beneficence. 1.- Provide Care with Compassion
  • 24. 24 • Therefore, within the role of care provider of a HCO • the competition, • compassion, • trust and • shared decision making • They form the basis of a binding principle: – provide compassionate care. 1.- Provide Care with …..
  • 25. 25 • While the role of the care provider is primarily informed by clinical ethics, the remaining roles - employer, care and manager - are based on the field of business ethics. • The duties of employers towards their employees are related to the rights of workers and the trade union movement. • Kant's principle of "respect for people" is invoked to argue that businesses should treat their employees as ends in themselves, and not just as means to increase productivity and profit. 2- Treat employees with respect
  • 26. 26 • The relationship between the employer and the employee is one of reciprocal responsibility but with a differential of power in favor of the employer. • The duties of the employer include: – the provision of fair remuneration, – ensure safe working conditions, and – reward and discipline fairly. • This requires protecting employees from discrimination and persecution in the workplace • And allow to express opinions about politics in ethical matters. 2- Treat employees with respect
  • 27. 27 • Organizations can and must empower their employees to become responsible actors by creating an ethical climate and serving the self-actualization of their employees. • Such empowerment is a prerequisite for employees to take responsibility for their actions and not hide behind rules and structures. 2- Treat employees with respect
  • 28. 28 CASE A nurse has a wound caused by a hypodermic needle when treating a high-risk patient, and the patient refuses to be tested for HIV. ¿?
  • 29. 29 • If the patient is HIV positive, prophylactic treatment can reduce the nurse's risk of HIV infection. • If the patient is HIV negative, prophylactic treatment offers no benefit, is costly, and exposes the nurse to the collateral risks of gastrointestinal problems, bone marrow suppression, and unnecessary stress. Analysis of the case: Conflict between Principle of compassionate care and Principles of respectful treatment of employees
  • 30. 30 • Clinical ethics, with its focus on the patient's rights to self-determination, can favor respect for the patient's autonomous decision to refuse the HIV test. • The nurse, however, also deserves respect, and the Health Care Organization has a moral duty to its employees to minimize health risks related to the workplace. • In this case, duty towards an employee may outweigh the patient's right to refuse an HIV test. Proposed solution
  • 31. 31 • Citizens' expectations regarding caregivers and Health Care Organizations include: – participation in a democratic society, – the responsibilities that businesses generally have with respect to society, and – the special responsibilities that health care entails. 3.- Act with a public spirit
  • 32. 32 • The Health Assistance Organizations have the duty to obey the Law. • In return, they obtain benefits from the obligations of the State regarding: service, protection, respect for rights, and receptivity towards citizens as consumers and taxpayers. • Some theorists of business ethics have argued that, in return for granting companies their legal status as independent entities, Society has the right to expect from them a positive net contribution to the general good. 3.- Act with a public spirit
  • 33. 33 • This is especially valid for businesses involved in providing health care, because in a double sense, it is a basic social good: – First, the granting of health care and compassion has intrinsic value that complements the social dimension of humanity. – Second, like food, education, and housing, health care is a good that people need to thrive and get the most out of their opportunities. 3.- Act with a public spirit
  • 34. 34 • Adequate health care is a prerequisite for the normal functioning of modern society, therefore, businesses that provide this type of good support special social responsibilities, regardless of their profit-generating status. 3.- Act with a public spirit
  • 35. 35 • It is expected that Healthcare Organizations can fulfill their citizen role through; – the proper disposal of hospital waste, – provision of free services and outreach to those who do not have access to care, and – support in matters that are of interest to public health. 3.- Act with a public spirit
  • 36. 36 • The principle of acting with a public spirit is also relevant with respect to: – the kinds of service that are provided, – how to ensure access to them, – how the actions of organizations and their members are perceived, and – how those actions can affect a broader community. 3.- Act with a public spirit
  • 37. 37 Example • The case of corporate social responsibility occurred in 1982, when several flasks of Tylenol were sabotaged, resulting in seven deaths. • The CEO of Johnson & Johnson was frank with the press and the public, removing all stocks from store shelves at a cost of US $ 105 million, and immediately ordered the development of inviolable containers.
  • 38. 38 • The administrators of the Health Assistance Organizations are in charge of promoting the success of their institutions, within the availability of resources. • The demands of the stakeholders must be prioritized according to the purpose and mission of the organization. • Because the reason for an HAO is to take care of the health of the patients, the basic obligation is defined by the principle of caring with compassion and making compatible with the generation of surpluses. 4.- Spend resources reasonably
  • 39. 39 • Market forces can induce dilemmas for the care mission of a Healthcare Organizations, and their managers must balance the sustainability and financial performance of the organization with other roles and responsibilities. • Administrators face the task of setting ethical limits in a deliberate, fair, and transparent manner. 4.- Spend resources reasonably
  • 40. 40 • The four principles of organizational ethics provide a framework for discussing the moral obligation of healthcare providers. • The relative weight of each principle will depend on the type of organization. – In provider organizations, compassionate care will be a priority, whereas in an insurance company, acting in a public spirit can be of special importance. CONCLUSION
  • 41. 41 The Principles are sufficient? • In addition, sufficient budget is required to finance the operation and development of the Health Assistance Organizations: – State funds – Private funds • Donors – Beneficiaries of the health system – Health Insurance Companies