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New Academic Medical Center Planned for Downtown Las Vegas New Task Force Hopes to Strengthen Chairs Roles as Institutional Managers
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A Word from the PresidentLeveraging the Power of Ethical Norms
That was a novel idea - novel at least to me - that an institution might need a code of ethics that was somehow distinct from a code designed to remind individuals about their personal and professional ethical obligations. The premise posed by Spike and Nancy Dubler, LL.B., the director of Montefiore's Division of Bioethics, is that health care institutions have certain obligations that can, and must, be distinguished from the aggregate obligations of the individuals composing their work force, including its leaders. This is not to suggest that an institution's doctors and staff don't have ethical obligations of their own; of course they do. And their ethical behavior, especially that of the institution's leadership, is absolutely essential for the institution to fulfill its avowed responsibilities. But according to this line of reasoning, the collective behavior of individuals within an organization does not fully express the organization's impact on everything that transpires in its name. Using the terminology of an ethicist, health care organizations are seen, in this view, to have "moral agency," and consequently are to be held accountable for their behavior, just as individuals are. On reflection, I find this concept quite compelling. Focusing attention on the organization itself, in addition to the individuals who work on its behalf, offers the potential, it seems to me, for developing a workable strategy to drive the fundamental changes needed to transform our broken health care system. Among the areas that Spike and his colleagues identified as ones for which Montefiore, as an institution, should be held accountable are those at the very top of the list of challenges we face. Examples include fostering quality health care; managing finite resources responsibly; promoting multidisciplinary case management; ensuring the privacy and confidentiality of patient information; and crafting a socially responsible agenda. Now, I would be the last one in America to suggest that we should drop everything we're now doing by way of convincing individuals to adopt new norms of clinical behavior and instead direct all of our attention on the behavior of organizations. Clearly, if we are to construct a cost-conscious, quality-driven, patient-oriented, easily accessible health care system for this country, getting physicians and other key individuals to change their traditional ways of doing things is absolutely essential. Essential, yes. Sufficient? Perhaps not. Maybe what's prevented more progress toward the agreed-upon goals for our health care system is our tendency to rely exclusively on individuals to do the right things and our failure to recognize the critical role played by institutional norms of behavior. Institutions do have norms of behavior, whether implicit in their traditions or explicitly stated by their governance. And don't those norms of behavior serve to create the ethical climate and organizational aspirations for those who labor within their walls and on behalf of their missions? No one could fail to recognize how easily organizational norms of behavior can undermine the delivery of high-quality, ethical medical services by those working on an organization's behalf. Witness the egregious behavior unleashed by some of the more disreputable managed care outfits that grew out of recent "market reforms." By the same token, organizational norms of behavior have just as much potential to reinforce high-quality, ethical medical services. But absent a set of clearly articulated principles laying out an institution's highest aspirations for itself, that potential for reinforcement may never be realized. To think otherwise is to suggest that professional norms of behavior, articulated by respected professional societies, play no role in influencing the way individual physicians fulfill their obligations in the doctor/patient relationship. Professional codes of ethics, as an expression of the shared standards of "the collective," strengthen personal resolve to fulfill the noble expectations of professionalism. By analogy, an explicit articulation of organizational norms of behavior, representing the avowed standards of an institution's collective governance, can reinforce an individual's resolve to live up to the ideals at the core of the institution/society relationship. Indeed, it was largely out of a desire to capture that reinforcing potential that Montefiore was motivated to promulgate its organizational code of ethics. By committing the institution to live up to a set of principles, and by stipulating the specific operational mandates required to do so, such a code could serve as a model for a new level of accountability. If academic medicine in general were to pledge fidelity to a similar set of principles, we might well witness a quantum leap toward achieving real progress in transforming America's health care system.
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Contact Us © 1995-2008 AAMC Terms and Conditions Privacy Statement |
I
heard a presentation recently by Spencer "Spike" Foreman,
M.D., who planted a thought in my head that I have been pondering
ever since. Spike, as many of you know, is the president of Montefiore
Medical Center in the Bronx and is a former chair of the AAMC. In
his presentation, he described a "code of ethics" that
he and his colleagues developed, not for the doctors and/or the
staff of his institution, but for the institution itself!