Ethics Leadership

Recent corporate ethical scandals have brought the subject of ethical behavior in the work place to the forefront. Institutions of higher learning are now instituting ethics classes to address the topic with future leaders. (Kubal, et al, 2006) Implementation of an ethics program must begin at the top of the leadership pyramid and permeate a company’s business philosophy. Steps taken by leadership should reflect the organization’s vision and corporate goals should include an ethical approach to business.

Creating an organizational identification with ethical behavior must begin with and be reflected by leadership. Employees watch leadership and take cues from them. A manager who speaks out against unethical behavior, but is quick to take the easiest route, no matter the ethical consequences, will tell his/her employees that ethics are important until they make life harder.

Every organization should have a vision, and that vision should have ethics as part of its core. (Kubal, et al, 2006) Placing statements of commitment to ethics on the walls will help keep the desired company character in the line of vision on a daily basis. The organization should have a code of conduct that supports employee’s ethical behavior and provides a framework for reconciling difficult situations. (Kubal, et al, 2006)

Many organizations have an ethics committee, often with the primary purpose of avoiding legal consequences and maintaining compliance with governmental and professional regulations. Leadership needs to support an ethics committee role that is integrated into the organization and supports the overall vision. The ultimate goal of an ethics program is to create a healthy environment for all stakeholders. This will in turn protect the organization from potential unethical behavior. Self-preservation should not be the primary goal of an ethics program, but should support the vision of success and to be positive member of the community. ((Kubal, et al, 2006)

Leaders in health care and other industries should take an active role in the education of future leaders. Creating a system, in which, leaders of industry could share their experiences, can aid students in learning the very relative subject of ethics. The communication of oral history to students could be accomplished with lectures by leaders to a group of students, or an interviewing process by a small group or an individual. (Topping, et al, 2006)

The prevalence of online courses often eliminates the assembly of a class, thus making a guest lecturer difficult to arrange. In the future, with web cams and conference meetings online, this may change, but for now getting web-based classes together is a difficult challenge. An optional exercise for students is to interview a local leader about experiences in ethics. (Topping, et al, 2006) This allows a student to understand issues in a local market she/he is familiar with and hopefully better relate to the issues.

As part of any commitment by a health care organization, there must be an investment of resources. Personnel need to be assigned and supported in positions that maintain the organization’s vision. (Kubal, et al, 2006) Health care organizations need to synchronize the ethics program with the community and stakeholders that are served. This includes sharing ethically reinforcing actions taken with stakeholders and reinforcing the commitment to ethical behavior. (Kubal, 2006)

Everyone has their own idea of what is ethical, and has their own commitment level to these ideals. The challenge is for leadership to bring the organization together with positive education, positive accountability and reinforcement. Management must model the ethical behavior supported in the organization vision. Finally, ethics is not a goal, but rather an ongoing journey that is evolving and changing and leadership must have a watchful eye on the organization’s ethical standing at all times.


References:

Kubal, D., Baker, M., Coleman, K., (March, 2006), Doing the Right Thing: How Today’s Leading Companies Are Becoming More Ethical, Performance Improvement, 45, 3, 5-9.

Topping, S., Duhon, D., Bushardt, S., (2006), Oral history as a classroom tool: learning management theory from the evolution of an organization, Journal of Management History, 12, 2, 154-161.

Dealing with Unethical Behavior

Unethical behavior can have a devastating impact on an organization. When inappropriate actions occur, leaders must aid the employee to take corrective steps. The action taken by leaders will vary with the degree of infraction. Corrective initiatives may mean counseling or may mean dismissal. However, corrective behavior begins with leadership and the creation of an ethical work environment.

There can be many reasons for unethical behavior, but there is no excuse that is acceptable for placing an organization’s stakeholders, especially patients, and the organization itself at risk. This is a time of high sensitivity to unethical behavior. The media has covered many stories of individuals who have been hurt by trusted industry leaders who have acted unethically.

An employee can behave unethically personally and or professionally. Both can have an impact on the organization, but managers must tread carefully when correcting personal behavior. Personal illegal behavior can not be harbored or covered up and needs to be addressed. Failure to do so puts the organization at risk and gives the appearance of an environment that supports such behavior.

One of the most important steps leaders need to take is the creation of an ethical culture of behavior. (Applebaum, 2006) Developing a highly ethical environment will produce employees who are unwilling to accept compromise and will be more likely to stand up for high moral standards. Accountability is a strong deterrent and will help stabilize unhealthy behavior.

Creation of a healthy ethical environment begins with leadership. (Wimbush, 1999) Managers who do not lead in this area will lack credibility in times when there must be correction of employees. Continual communication with employees is vital. This will open the door for employees to ask questions and avoid potential problems. However, it will also open the door for employees to understand the manager better.

If unethical behavior does occur the first step is to gain all of the facts and counsel the employee. There should be documentation of the discussion and a comment of resolution. Follow-up monitoring should occur in a supportive environment. For more egregious acts, or if unethical actions continue, the employee should be reprimanded and the ethics committee may need to be made aware of the incident.

If the behavior is deviant and is of a nature worthy of dismissal, the employee needs to be fired. Care needs to be taken in providing all employees with a consistent message that ethical behavior is very important to an organization. This begins with leadership, and then trickles down. Organizational policy and procedure must be followed and leadership needs to be in consistent communication with department managers in order to maintain the organization’s journey to attain the set goals.


References:

Appelbaum, S. H., (September, 2006), Diagnosis and Remedies for Deviant Workplace Behaviors, Journal of American Academy of Business, Cambridge, 9, 2, 14-21.

Wimbush, J. C., (February, 1999), The effect of cognitive moral development and supervisory influence on subordinates ethical behavior, Journal of Business Ethics, 4, 2, 383-396.

Ethics of Prevention Methods for Youth and Steroids

Steroids have received a lot of attention in the media lately. Steroids are credited with enhancing the performance of professional athletes and have created uproar for testing to clean up professional baseball. Many youth athletes in the United States have noticed steroids, as well. Testing is expensive and cost prohibitive for most high schools and youth programs. The best way to address the problem is with education and an active involvement by parents, coaches and medical professionals.
Steroids are not only available in high schools and colleges, but in middle schools. (Ungerleider, 2001) Use of steroids in middle schools and high schools is consistent. 2.7 percent of eighth and tenth graders and up to 6 percent of high school student-athletes admitted to researchers that they use steroids. (Ungerleider, 2001)
Most focus in the professional sports arena has been on testing and punishment. The cost of testing is high, but there are also legal and ethical issues with testing minors. Parents and guardians must give approval for testing. Should public schools be the setting for testing? Testing is policing actions that school systems are not equipped to handle.
Schools are equipped to teach and this is the first line of defense when dealing with steroids in youth. Education should include the health risks involved with the use of steroids. Education, without scare tactics, is an excellent way to make student-athletes aware of the negative side. Education should be for all students, since steroids are being used for cosmetic reasons, not just for performance enhancement.
Parents need to be involved in the education and monitoring of their children. School systems should provide information to parents regarding warning signs to look out for. Also, helpful tips for discussing with their children the subjects of substance abuse and illegal drugs should be provided to parents. (Anonymous, 2006)
Ethically and economically, education and counseling is the best way to provide help to youth. It can get parents involved and provide a firmer foundation of support. Students are seeing young athletes make millions of dollars, and while it is a very small percentage, the temptation to be the next sensation is strong. Education must be stronger and include all key people at school and at home.

References:

Anonymous, (January/February, 2006), Preventing Steroid Use in Youth, Journal of the American Chiropractic Association, 43, 1, 17-18.

Ungerleider, S., (May, 2001), Steroids: Youth at Risk, Harvard Mental Health Letter, 17, 11, 4-5.

Prenatal Screening for Down Syndrome: Ethical Approach to Results

Advances in technology have made information available to clinicians and patients information that was never available before. Having information does not mean people will know how to use it. Prenatal screening for disabilities gives parents important information, but it can take professionals to help provide context for resulting actions.
Lynn and Bob knew they would be parents in July of 2000. With the determination that there was a risk involved Lynn had an amniocentesis and the test came back for positive Tri 21 Down syndrome. A meeting was scheduled with a genetic counselor to discuss pertinent information.
The meeting opened with basic information, but quickly turned to the options for carrying the pregnancy to term. The parents informed the counselor that a decision had already been made and the couple would have the baby. The counselor then discussed the potential severity of the handicap and stated the quality of life would potentially be poor. Counseling the parents that the child could be a burden to the parents and to society, the counselor stated that abortion was a viable option. Bob was firm that the couple planned on making the baby part of their family.
For a third time the counselor continued, but now stating that abortion has had a stigma in the past, but that in this day and age is a viable option and that it is not uncommon for couples to abort a fetus with special needs. The couple, very firmly stated that they understood the information and that they would sign any paperwork needed to state they have been informed. However, if the discussion continued with talk of abortion, the couple would consider the session over and leave.
Many states require phenylketonuria (PKU) testing to determine possible disorders. (Holtzman, 1997) Testing may require further tests such as (amniocenesis), but depending on socioeconomic circumstances not all testing may be done. (Khoshnood, et al, 2004) Even if testing is done, not all mothers or couples will receive counseling. Information is very important, not only to make hard choices, but to prepare parents for parenting.
Medical professionals will often be the first to provide information to parents who find out their baby has special needs. This is a very heavy responsibility and should never be taken lightly. Professionals need to make sure they present empirical information and leave personal opinions at the door. Finding out a child has special needs can cause some shock, and during vulnerable times such as these, professionalism with compassion is vital.

References:

Holtzman, N. A., (August, 1997), Editorial: Genetic Screening and Public Health, American Jounral of Public Health, 87, 8, 1275-1278.

Khoshnood, B., Blondel, B., De Vigan, C., Breart, G., (March, 2004), Socioeconomic Barriers to Informed Decision making Regarding Maternal Serum Screening for Down Syndrome: Results of the French National Perinatal Survey of 1998, American Journal of Public Health, 94, 3, 484-492.

The Schiavo Case, the Law and Health Care Ethics


The case of Theresa Schiavo garnered a lot of publicity and attention nationally and even internationally. The case to take her off life support promoted emotional reaction and heated debate on both sides of the euthanasia debate. However very few facts regarding the actual facts and legal precedent made it into the general information war that took place in the press. The court system did its job by ruling on the facts of the matter, while political posturing was shaping public opinion.
On February 25,1990 Theresa Schiavo, wife of Michael Schiavo and daughter of Robert and Mary Schindler, suffered cardiac arrest due to a potassium imbalance, causing decreased oxygen to the brain and loss of consciousness. After numerous legal battles over guardianship and termination of life-prolonging procedures, on October 15, 2003 nutrition and feeding tubes were removed from Theresa Shiavo. Following this action, the Florida Legislation passed Chapter 2003-418 on October 21, 2003 and which the Governor signed into law and has come to be known as “Terri’s Law”. The Governor then signed an executive order, which lead to the reinsertion of nutrition and feeding tube as a life-prolonging procedure. On October 21, 2004, Michael Schiavo, husband a guardian for Theresa Schiavo, filed suit for declaratory judgment in the circuit court of Florida arguing “Terri’s Law” is unconstitutional. Circuit court found the legislative act to be unconstitutional. (Bush, et al, v. Schiavo, 2004)
Those opposed to euthanasia painted the issue as a life-saving attempt by the Florida government, lead by Governor Jeb Bush. Many felt the ruling gave a support for euthanasia, however, that is not what the ruling was about. The legal arguments centered on the ability under Florida constitution for the government to make such a law as “Terri’s Law”. The facts of the medical condition where not the issue, even if they did not demonstrate a sustained life condition.
In another case, Robert and Mary Schindler, parents of Theresa Schiavo, appealed to the District court of Florida for relief from the ruling that their daughter, being in a persistent vegetative state, would have elected to forgo life-prolonging tubes. Appellants also ask the District court for a motion to stay the removal of the feeding tube pending appeal. It had already been established in court that Theresa Schiavo was in a persistent vegetative state and would have declined the continuation of life prolonging treatment. (Schiavo v. Schiavo, 2005)
The Schindlers filed for relief on behalf of Theresa Schiavo based on two arguments. First, that the trial judge, and not a guardian for Theresa Schiavo, made the decision for Mrs. Schiavo. The parents argue that the circuit court judge does not have the authority to make such a decision. Second, the parents argue that any judgment made without Theresa Schiavo having the full and fair opportunity to defend her rights in court.
The parent’s motion was denied. Courts have consistently followed well-established laws directing guardianship and have even gone well beyond the normal procedures. Also, no new evidence was presented that the patient’s status or prognosis has changed. Many times both the parents and the guardians have presented evidence and had opportunity to present or refute evidence. Not only has the patient received due process, but also every effort has been made by the courts at every level the case has been heard to meet or exceed every law guiding this decision.
The parent’s grief is understandable and the desire for different moral and ethical camps to state their cases was also comprehended. However, the courts demonstrated in the face of public and political pressure the ability to stand up for the law. Medical ethics and law go hand in hand. It may not be a perfect system, but it is a lot better than has been portrayed. It is extremely dangerous when moral and ethical camps get involved politically. Those wishing to gain political clout, often distort what begins as a truly noble attempt to fight for a belief. Health care leaders must work with legal counsel and rely on the law and scientific empirical evidence to direct actions during heated times. Wise counsel is always good




References:

Bush, et al, v Schiavo, Supreme Court of Florida, No. SC04-925, September 23, 2004, (Reheard, October 21, 2004

Schiavo v. Schiavo, District Court of Appeal, No. 2D05-968, March 16, 2005.

Financial Impact of Technology

Health care spending has grown continuously since 1960. Health care technology and an increasing demand for services are two of the primary drivers of the overall increases in health care expenditures. (Iglehart, 2006) The strategy to increase and/or update a health care organization’s technology is not new, but the challenges faced by leaders to weigh the advantages of a plethora of choices are intense. Technology has greatly enhanced our lives, but not without a cost. Passing along the cost and deciding who will receive more expensive, technologically enhanced care is the challenge.
Information technology has been enhanced greatly. The health care industry has lagged behind many other industries in implementing information technology, but the execution of new computerized systems has been drastically increasing. While capital spending leveled off in the late 1990s, spending for health care has increase almost fourteen percent per year this decade. (Cove, et al, 2006) Operations’ earnings are being relied upon to fund increased capital purchases, which makes an uphill climb for low-margin organizations to compete. (Cove, et al, 2006) Many organizations that operate with a low-margin are also those that serve the financially disadvantaged. We can argue that our healthcare system is a business and operates in a capitalist market, but can we say the playing field is level?
On an individual level, many Americans are gaining access to information through the Internet. Medical information and even contact with medical offices is now available electronically. (Natesan, 2005) However, many Americans cannot afford personal computers. While public libraries offer access, this is rarely feasible for many working families.
Another example of the growing gap in medical care spending is with reproduction. Many couples struggle to create a family and while technology has created many options for couples, cost is a limiting factor. Lead by the Clinton administration, health care reform attempted some dramatic changes in the financial structure of funding the health care system. Even with these changes, Assisted Reproductive Technologies (ART) were not included in the plan. (Robertson, 2006) Few, if anyone, are about to ask Medicaid to fund ART, but for those without the means, options are very limited. Before we argue that adoption is a viable option, for many this can be even more costly. With waiting lists in the United States and a large need for adoptive parents internationally, the system to adopt can be a challenge. Costs to adopt internationally can easily run in the tens of thousands of dollars.
As mentioned above, institutions that operate with a low-margin and little room for financial mistakes, are often those who provide care to the most disadvantaged. This becomes a significant challenge to provide care to certain populations. It becomes imperative that health care leaders, with tight budgets, look to invest in technology that is cost effective. (Cove, et al, 2006) Leadership-lead cost analysis studies must be a primary determination of choices in order to maintain viability. After tough choices are made, other solutions must be found. There needs to be greater partnering between organizations to facilitate cost effective care with greater access.
Mistakes made by leaders can be greatly magnified in an era when the health care system is evolving so quickly. The health care system needs to award institutions that work together for the betterment of society, in spite of competition.




References:

Cove, M. J., Kell, J., (January/February, 2006), How Hospitals Confront New Technology, Health Affairs, 25, 1, 163-173.

Iglehart, J. K., (January/February, 2006), U.S. Hospitals: Examining Their Fraying Social Contract, Health Affairs, 25, 1, 8-9.

Natesan, C. N., (September, 2005), The Impact of The Internet on Health Care Services, Journal of American Academy of Business, Cambridge, 7, 2, 247-251.

Robertson, J. A., (January/February, 2006), Normalizing Assisted Reproduction, Health Affairs, 25, 1, 291-292.

Sorry Seems to Be the Hardest Word

Should health care providers apologize when a medical error occurs? There is a growing feeling that the answer to this question is “yes”. Both the American Medical Association (AMA) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) state full disclosure to the patient should be made when a medical error occurs. (Leape, 2006) However, there is a big difference between full disclosure and an outright apology to the patient.
Two of the main arguments behind advocating apologies are that lawsuits are avoided and healing can begin both for the patient and the provider. (Leape, 2006) According to a report from the American College of Physician Executives (ACPE), feelings are mixed, but many executives feel open communication that includes an apology will avoid many lawsuits. (Weber, 2006) Resentment by patients who feel physicians and healthcare organizations are less than honest is sited as a major reason to advance tort claims. Many patients and family members file suit to find out the truth. (Leape, 2006)
The need to begin healing for both the patient and the provider is reported as a primary reason to give an early apology. One hospital executive in Wisconsin reports that she/he sees physicians come to terms with their mistakes by offering an apology. (Weber, 2006) Leape also states “Apology is not an ethical right, but a therapeutic necessity. Apology makes it possible for the patient to recognize our humanity, our fallibility, our remorse at having caused harm.” She adds, “It makes it possible for the patient to forgive us.” (Leape, 2006) While I see the value of apologies in the healing process, I disagree that apologies are a needed step for forgiveness. Alexander Pope is credited with the famous quote, “To err is human, to forgive divine.” The choice to forgive or not to forgive lies with the patient. An apology does not predetermine forgiveness and forgiveness can be given without an apology. That power lies at all times with the offended party. While a positive step in healing, there are many views to consider before quickly offering an open apology.
Practitioners need to be aware of their relationship to other healthcare provider’s, organizations and insurance companies and understand that their actions can impact with many individuals including their patients. There are many relationships with the issue of trust to be considered when a medical error occurs. Ten states now have laws on their books that protect a physician’s apology from being admitted as evidence in court. (Weber, 2006) The National Medical Error Disclosure and Compensation (MEDiC) Act of 2005 has been introduced to congress which protects a physician’s apology and requires time for parties to negotiate compensation for damages. (Weber, 2006) Even with these positive steps, an apology can be risky. A physician who apologizes for his/her individual actions could be including the entire medical team and system. At other times it may be determined later on that the individual apologizing actually was not at fault, too late to take back words spoken. (Butcher, 2006)
Many lawyers and risk managers still feel an apology, no matter how well intended can be used as an admission of guilt. A professional who utters the words, “I am sorry” needs to know what they are admitting to. Many lawyers agree that offering an apology to a patient becomes very difficult to defend against. (Butcher, 2006) While an apology may head off possible litigation, that same apology could be the evidence that a physician will regret.


Butcher, L., (March/April, 2006), Lawyers Say “Sorry” May Sink You In Court, Physician Executive, 32, 2, 20-25.

Leape, L., L., (March/April, 2006), Full Disclosure and Apology – An Idea Whose Time Has Come, Physician Executive, 32, 2, 16-18.

Weber, D. O., (March/April, 2006), Who’s Sorry Now?, Physician Executive, 32, 2, 6-12.

What to do?

Early in my career, I worked as an athletic trainer for a company I am not currently with. I was contracted out to a school with a dominant football program. We had two excellent running backs and in week eight of the season one of the running backs fractured his wrist. Five weeks later in the state playoff quarterfinal game, the second running back fractured his wrist during the Friday night game. On Saturday morning the running back saw our team physician and was placed in a splint. It was clear his season was over and it was going to be difficult for our team to win the state semi-final game without him. Prior to these injuries we were the favorite to win the state championship.

All season long the head football coach and athletic director for the school had put a lot of pressure on me to keep student-athletes playing, even when it was questionable or clear the student-athlete should not be participating.

On the following Tuesday afternoon, prior to practice, the schools athletic director and head football coach pulled me aside and told me the mother of the player who had been injured four days prior, wanted her son to play. A doctor had not cleared him but the player would play and if I had a problem with it I should leave immediately. No written permission from the mother was presented and only the word of the school officials was given. The fracture site was at the epiphyseal joint causing a significant risk for further damage if the athlete injured his wrist further. What was I to do? If I left, I was walking out on 60 other student athletes. Many of which I was providing treatment or splinting and/or taping for prevention. Also, if someone was injured after I left, there was not a trained professional present to provide care. If I stayed I could put both myself, and my company in a position of increased liability if I treated a player without proper clearance to return to activity. I had to think quickly and make the right decision.

I told the athletic director and the head coach I did not agree with their decision to allow the student-athlete to compete and questioned the information the mother was receiving. I had spoken with the mother on Saturday after her son had seen the physician and she gave no indication she wanted to see her son play. I further stated that I would not leave the team, but I also could not provide any treatment, such as padding, splinting, taping or a soft cast, to the injured athlete in question. I also informed the athletic director and coach I would discuss further action with my supervisor.

I immediately called my supervisor and informed him of the situation. His immediate reaction was to have me follow my plan and he called our company lawyers to seek clarification. The next morning I met with my supervisor and we decided to draft a letter to the school district superintendent expressing our concern for the student-athlete, the schools liability, and our position that we would not provide care to the concerned party unless it was a new acute situation. We hand delivered the letter that day, Wednesday, to the school district office and also faxed the letter to our lawyers.

The superintendent of schools did not know about the situation until we notified him. He immediately took the case to the school’s lawyers and they then informed the school that the athlete could not play unless cleared by a physician.

The reaction of the head coach was to blame me for the athlete’s inability to play that Friday and the team subsequently lost the state semi-final game that Friday.

Our reaction was to protect the injured student-athlete and also the rest of the team by attempting to work through proper channels. If I had walked out of practice when first confronted, this could have ended very ugly. We did a number of steps correctly. We saw the ethical issues involved and thoughtfully reacted. We properly identified the stakeholders including the entire team. We looked at the possible effect on our organization as well as the school district including the student-athletes. We sought wise counsel from our colleagues, including legal advice. Finally we utilized our key resources, primarily our relationships with the superintendent, to seek a successful solution. This was an excellent learning experience in a very heated environment.

Welcome to RobertBuEthics. My name is Robert M. Burton. This site is for University of Central Florida Health Care Ethics class HSC 6656, summer 2006 semester. I welcome and look forward to your comments and feedback.

A little bit about myself. I am clinically trained as a Certified Athletic Trainer and am licensed in the state of Florida. I currently work as the Sports Medicine Coordinator for an HCA owned hospital in St. Lucie County, Florida. My planned graduation date is after the Spring semester of 2007.

Welcome and I hope you enjoy this site.