Not just financial advice: Trustees untapped resource for ethics guidance
Ethics scholar says language of ethics not part of trustee’s world’
When the topic of medical ethics comes up in conversation or literature, it usually refers to the ethics of providing direct patient care. But the ethics of hospital trustees have a profound influence on the delivery of care and the overall health of nonprofit hospitals, and yet there has been very little examination of the ethics of trusteeship.
"People who are trustees don’t think in explicitly ethical terms and concepts about their role," says Bruce Jennings, BA, MA, senior research scholar at The Hastings Center in Garrison, NY. "They understand their responsibilities involve values, but the language of ethics is not part of the trustee’s world in the way it has become part of the physician’s world and the clinical world."
Jennings was part of a collaborative effort between The Hastings Center and the New York Academy of Medicine that interviewed trustees and chief executive officers from about 20 nonprofit hospitals in the New York area and elsewhere, and examined trusteeship from historical, legal, ethical, and empirical perspectives.
"There are clearly a variety of negative ethics and positive ethics issues that are part of trusteeship in all organizations — for profit, not for profit, etc.," says Jennings. "We’ve seen the negative side — lots of scandals, conflict of interest, misuse of funds — that implicates the boards and trustees, showing that boards are not well informed, or are rubber stamps for the CEO, or at least aren’t living up to the expectations and responsibilities of being trustees."
The decisions made by hospital trustees can include such weighty moves as whether to sell or not to sell a hospital; how to respond as an institution to medical errors; allocating large financial resources; responding to changing community needs; and even whether to shut down a hospital. For those reasons, Jennings points out, establishing a way to educate trustees about their ethical obligations should be considered an important health care issue.
Nonprofit hospital trustees are volunteers from an array of backgrounds — usually business, and rarely health care. They are usually well known and well connected in their communities, and often have a wide philanthropic streak. They are entrusted by financial supporters, health professionals, and patients and their families to address issues that affect life and death, overall quality of health care, and the interests of the community.
"We take for granted that people should be honest, avoid conflicts of interest — the positive ideas about trustees and their moral ideals," says Jennings. "But there’s very little out there in the way of self-education or preparation for being a trustee. You don’t get a degree in trusteeship.
"Also, the trustee community is not very well organized. There is no [national] association for trustees. People are chosen [to become trustees] for their leadership and philanthropy. It’s very localized; there’s no state or national organizations that do trustee training and education."
The American Hospital Association, noting the dearth of resources for hospital trustees, created the Center for Healthcare Governance as a source for innovating thinking, information, tools, and counsel for health care-governing bodies and officers. A periodical magazine published by the center, Trustee, covers issues pertinent to hospital and health system governance.
Jennings and his colleagues compiled their findings into a book, "The Ethics of Hospital Trustees."
"We emphasize in the book that the core value is the trustee’s commitment to the mission of the organization," he says.
The trustee’s main lines of responsibility are to the hospital’s patients, to the institution itself, and to the community.
"It differs from [clinical] medical ethics in that you have to talk in more systemic, community, and organizational and institutional terms. It’s not just the patient-centered dyad, and that makes it both interesting and complex," Jennings explains.
While some might view trustees of a hospital as little different from the trustees of a company owned by shareholders, Jennings says the difference is that trustees for a nonprofit hospital don’t have shareholders to answer to — their concern should be only the hospital’s mission to treat illness and promote health.
"And I think there’s something special about that," he adds. "There are moral responsibilities for those who are trusted to run these institutions to make modern health care possible, and that’s of special moral importance."
The Hastings Center/New York Academy of Medicine study found that the trustees interviewed are almost completely preoccupied with the financial turmoil of the health care system. Jennings says this is, of course, an important concern, because if a hospital goes bankrupt, the community loses its hospital.
"But to turn trustees into narrow financial advisors is a great loss of what they could be doing both inside and outside the hospital," he says. "Trustees should be more knowledgeable about quality of care, patient safety, and medical errors. These are serious problems in America, if the [Institute of Medicine] reports are correct. You can’t just worry about Medicare rates and finances; you have to hold responsible managers accountable, and they have to be knowledgeable about standards and performance."
While there are materials available that discuss the various roles of hospital trustees and directors, Jennings says ethics is "a wide open field."
"There’s a fairly large [amount of] literature out there on trustee/board communication, but discussion of ethical responsibility is not part of that in any way," he says. "Our study tried to create a basis and a few materials for teaching boards to think more explicitly, more systematically about the ethical aspects of their role."
The Hastings Center/New York Academy of Medicine group sought to advance the dialogue on trustee ethics by assembling a collection of essays on the topic, and drawing up a sample schedule for a board education session (see box).
"The implication of what needs to be done really is that trustees have to rethink the role of the hospital, frankly," says Jennings. "The hospital has been an isolated institution devoted to illness care, not terribly well integrated into the community and into community health and education, and I think that in the future, in terms of ethics and reorganizing the health care system and hospital system, we need to think of the hospital in more civic terms, as part of a community-wide effort."
Hospital trustees could seek to deal with distribution of care, chronic illness, and high-risk behaviors in their communities, Jennings suggests.
"I think what [the Hastings Center/New York Academy of Medicine team] was saying is that when you talk of ethics and hospital leadership, that hospital leaders need to think of their civic role and leadership role and to be part of the conversation, along with medical staff and hospital administration. Trustees ought to be an active part of reorganizing health care, not a rubber stamp for administration."
References
Jennings B, Gray BH, Sharpe VA, et al, eds. The Ethics of Hospital Trustees, Washington, DC; Georgetown University Press: 2004.
Jennings B, Gray BH, Sharpe VA, et al. Ethics and trusteeship for health care: Hospital board service in turbulent times. Hastings Center Report Special Supplement 2002; 32:S1-S28.
Sources/Resources
- Bruce Jennings, BA, MA, senior research scholar, The Hastings Center. 21 Malcolm Gordon Road, Garrison, NY 10524. Web site: www.thehastingscenter.org.
- Center for Healthcare Governance, One North Franklin, Suite 2800, Chicago, IL 60606. Phone: (888) 540-6111. Web site: www.americangovernance.com.
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