Is Organizational Ethics Part of Ethicists’ Role? It Varies Widely

By Stacey Kusterbeck

At many hospitals and health systems, ethicists are focused narrowly on consult requests involving individual patients. However, some ethicists take a broader, systemwide approach with their work. “Organizational ethics in healthcare is a relatively new field, having gained more prominence in the last couple of decades,” notes Tim Lahey, MD, MMSc, director of clinical ethics at University of Vermont Medical Center.

However, there are not much data on organizational ethics. “While there are plenty of articles on theories of organizational ethics, there aren’t many published descriptions of what organizational ethicists are actually doing on the ground in their healthcare institutions,” says Kelly Turner, a PhD student in Health Care Ethics at Saint Louis University.

Turner, Lahey, and colleagues conducted a survey to learn more about the work of organizational ethics and what ethicists were doing. “We wanted to bring some data to the question of how organizational ethics is practiced in healthcare nowadays,” says Lahey. In their own experience, the ethicists have seen varying degrees of engagement with organizational ethics. “I have worked in an institution that doesn’t pay much explicit attention to, or provide support for, organizational ethics and another in which organizational ethics is embedded in my colleagues’ job roles,” reports Turner.

The researchers surveyed 93 ethicists about how often they engaged in 14 organizational ethics domains.¹ About one-quarter of ethicists (23%) indicated that they do not do organizational ethics work at all. Yet all ethicists reported regularly conducting at least a few specific organizational ethics activities or domains. “There are likely ethicists out there who are doing organizational ethics work, but don’t recognize it as such,” Turner concludes.

Ethicists probably disagree to some extent on which activities should be considered “organizational” vs. “clinical” work. For instance, some ethicists view working on institutional policies as part of the “traditional” work of clinical ethicists. Others consider policy development to be organizational ethics. “The organizational ethics field has a lot of room to grow in terms of ethicists’ recognition and awareness,” observes Turner.

Ethicists varied widely in the types of organizational ethics work they were doing. Some examples:

• More than three-fourths (77%) of respondents indicated that creating institutional policies was something they engaged in often.

• Most (90%) respondents indicated they infrequently or never participated in disclosure of population-level risk.

• More than half (56%) of respondents reported that weighing the pros and cons of charitable fundraising strategies was not part of their role.

• About one-third of respondents indicated that creating or revising the institution’s mission, vision, and/or values statements was not part of their role.

Ethicists were asked about the top barriers to organizational ethics work. Few (16%) indicated that availability of organizational ethics expertise was a barrier. Instead, ethicists cited lack of resources, lack of funding, and lack of support from leaders as the predominant challenges.

Ethicists were given the opportunity to add additional comments about other barriers. Some reported having limited time and bandwidth. Others said that organizational ethics work was delegated to other hospital departments, such as compliance. Ethicists also noted a lack of access to institutional knowledge.

“One example of institutional knowledge that an ethicist might not have access to is awareness of a major upcoming business decision that’s going to affect patient care at the healthcare institution,” offers Turner. For example, hospital leaders may be deciding on whether to relocate or close a community hospital that is losing money. “Because the ethicist is not ‘in the loop,’ — that is, they aren’t being invited to meetings where healthcare leadership are discussing the various options — they can’t provide input on how each option implicates the institution’s values and commitments,” says Turner.

There are some differences in the expertise needed to perform organizational ethics work and the expertise needed to do clinical ethics work, acknowledges Turner. Organizational ethics work typically requires an understanding of the organization’s governance and decision-making structure, pertinent laws and regulations that guide healthcare delivery, and healthcare financing. “But for the most part, I’d say that ethicists have key skills that are necessary for applying reasoning to organizational ethics challenges,” says Turner. These include allocation of limited resources, conflict resolution, and identifying conflicting values in decision-making processes.

“Ethicists are telling us that they know how to help and see when to help. But they do not have the organizational influence to be able to use their expertise to help leaders with the issues they encounter,” concludes Becket Gremmels, PhD, system vice president of theology and ethics at CommonSpirit Health.

Some ethicists work in big health systems and regularly address a wide variety of topics with staunch support from senior leadership. “Others have a much more narrow topical focus, or far less support for the work,” says Lahey.

Regardless of the organization’s size, there’s a need for organizational ethics to have a voice, in addition to compliance functions. “We don’t just want organizations to do the bare minimum as is often implied in compliance, which focuses on adhering to external standards. We want organizations to do the right thing,” Turner explains.

Ethicists were asked about metrics used to gauge success of organizational ethics work. Sixty-one percent indicated that quality improvement (QI) work was triggered by recurring issues noted during clinical ethics consults. Thirty percent indicated that ethicists do not use any specific metrics to gauge their organizational ethics work. These findings suggest that ethicists either are not assessing organizational ethics work at all or, if they do, they are not doing it in a separate and distinct way from their overall clinical ethics work. “There’s a lot of work to be done to develop ways to assess organizational ethics work in a standard way that can give us insight into the quality and impact of that work,” says Gremmels.

While most ethicists are doing organizational work, it is happening to different extents and with varying levels of support. “This is a time of innovation in which people are rightly trying out new models. That can be, largely, a good thing,” says Lahey. However, lack of awareness of the bigger picture of organizational ethics hinders progress. “People might be reinventing the organizational ethics wheel, so to speak,” says Lahey. “My hope is that our work helps organizational ethicists know they are not alone, and that there are peers out there who have faced similar challenges.”

Some organizational ethicists are leading the way, with support from senior leaders. “Expectations are clear including about the domains of their work. A next step will be helping those exemplars share best practices with the whole field,” says Lahey.

The researchers hope that the study’s findings fuel conversations between ethicists and hospital leaders about the need for proper support for organizational ethics. “If ethicists can go to hospital leadership with a specific account of the ways that they can support institutional decision making, they may be more likely to gain adequate backing from leaders for that work,” offers Turner.

One way that ethicists can approach hospital leadership is to demonstrate the important organizational ethics work that they have already done in their institutions. Ideally, physician and nurse leadership will speak out in support of that work. “This is what some ethicists did in the immediate aftermath of the pandemic,” notes Turner. Some ethicists and their clinical colleagues went to leadership to explain how they supported the organization in a time of crisis, by designing scarce resource allocation frameworks and crafting visitation policies. “And once they’d demonstrated their value, they requested funding for formal organizational ethics programs,” says Turner.

Ethicists can approach hospital leaders in several ways, according to Gremmels. First, clinical ethics issues with individual patients often have organizational ethics components or implications. Ethicists can report on those cases to relevant department leaders to demonstrate the need for organizational ethics support. Second, ethicists can respond if an issue occurs at the organization that could have been prevented with organizational ethics. “Offer to retroactively review and identify potential actions to take to prevent similar issues in the future,” advises Gremmels.

Ethicists can also point to existing, successful programs in organizational ethics at other institutions. “This may be persuasive in establishing the legitimacy and importance of this field,” adds Turner.

REFERENCE

1. Turner K, Lahey T, Gremmels B, et al. Organizational ethics in healthcare: A national survey. HEC Forum 2024; Jan 17. doi: 10.1007/s10730-023-09520-3. [Epub ahead of print.]