What Is It That You Want Me To Do? Guidance for Ethics Consultants in Complex Discharge Cases

Omelianchuk, A., Ansari, A.A. & Parsi, K.

HEC Forum (2023).

https://doi.org/10.1007/s10730-023-09517-y

Abstract

Some of the most difficult consultations for an ethics consultant to resolve are those in which the patient is ready to leave the acute-care setting, but the patient or family refuses the plan, or the plan is impeded by deficiencies in the healthcare system. Either way, the patient is “stuck” in the hospital and the ethics consultant is called to help get the patient “unstuck.” These encounters, which we call “complex discharges,” are beset with tensions between the interests of the institution and the interests of the patient as well as tensions within the ethics consultant whose commitments are shaped both by the values of the organization and the values of their own profession. The clinical ethics literature on this topic is limited and provides little guidance. What is needed is guidance for consultants operating at the bedside and for those participating at a higher organizational level. To fill this gap, we offer guidance for facilitating a fair process designed to resolve the conflict without resorting to coercive legal measures. We reflect on three cases to argue that the approach of the consultant is generally one of mediation in these types of disputes. For patients who lack decision making capacity and lack a surrogate decision maker, we recommend the creation of a complex discharge committee within the organization so that ethics consultants can properly discharge their duties to assist patients who are unable to advocate for themselves through a fair and transparent process.

The article is paywalled.  Please contact the author for full copy.

Here is my summary:

• Ethics consultants face diverse patient situations, including lack of desire to leave, potential mental health issues, and financial/space constraints.
• Fair discharge processes are crucial, through mediation or multidisciplinary committees, balancing patient needs with system limitations.
• "Conveyor belt" healthcare can strain trust and create discharge complexities.
• The ethics consultant role is valuable but limited, suggesting standing "complex case committees" with diverse expertise for effective, creative solutions.

In essence, this summary highlights the need for a more nuanced and collaborative approach to complex discharges, prioritizing patient well-being while recognizing systemic constraints.

Will You Forgive Your Supervisor’s Wrongdoings? The Moral Licensing Effect of Ethical Leader Behaviors

Rong Wang and Darius K.-S. Chan
Front. Psychol., 05 March 2019
https://doi.org/10.3389/fpsyg.2019.00484

Abstract

Moral licensing theory suggests that observers may liberate actors to behave in morally questionable ways due to the actors’ history of moral behaviors. Drawing on this view, a scenario experiment with a 2 (high vs. low ethical) × 2 (internal vs. external motivation) between-subject design (N = 455) was conducted in the current study. We examined whether prior ethical leader behaviors cause subordinates to license subsequent abusive supervision, as well as the moderating role of behavior motivation on such effects. The results showed that when supervisors demonstrated prior ethical behaviors, subordinates, as victims, liberated them to act in abusive ways. Specifically, subordinates showed high levels of tolerance and low levels of condemnation toward abusive supervision and seldom experienced emotional responses to supervisors’ abusive behaviors. Moreover, subordinates tended to attribute abusive supervision, viewed as a kind of mistreatment without an immediate intent to cause harm, to characteristics of the victims and of the organization rather than of the supervisors per se. When supervisors behaved morally out of internal rather than external motivations, the aforementioned licensing effects were stronger.

Here is a portion of the Discussion

The main findings of this research have some implications for organizational practice. Subordinates have a tendency to liberate leaders’ morally questionable behaviors after observing leaders’ prior ethical behaviors, which may tolerate and even encourage the existence of destructive leadership styles. First, organizations can take steps including training and interventions to strengthen ethical climate. Organizations’ ethical climate is not only helpful to manage the ethical behaviors within the organizations, but also has impact on shaping organizational members’ zero-tolerance attitude to leaders’ mistreatments and questionable behaviors (Bartels et al., 1998).

Association Between Physician Burnout and Patient Safety, Professionalism, and Patient Satisfaction

Maria Panagioti, Keith Geraghty, Judith Johnson
JAMA Intern Med. 2018;178(10):1317-1330.
doi:10.1001/jamainternmed.2018.3713

Abstract

Objective  To examine whether physician burnout is associated with an increased risk of patient safety incidents, suboptimal care outcomes due to low professionalism, and lower patient satisfaction.

Data Sources  MEDLINE, EMBASE, PsycInfo, and CINAHL databases were searched until October 22, 2017, using combinations of the key terms physicians, burnout, and patient care. Detailed standardized searches with no language restriction were undertaken. The reference lists of eligible studies and other relevant systematic reviews were hand-searched.

Study Selection  Quantitative observational studies.

Data Extraction and Synthesis  Two independent reviewers were involved. The main meta-analysis was followed by subgroup and sensitivity analyses. All analyses were performed using random-effects models. Formal tests for heterogeneity (I2) and publication bias were performed.

Main Outcomes and Measures  The core outcomes were the quantitative associations between burnout and patient safety, professionalism, and patient satisfaction reported as odds ratios (ORs) with their 95% CIs.

Results  Of the 5234 records identified, 47 studies on 42 473 physicians (25 059 [59.0%] men; median age, 38 years [range, 27-53 years]) were included in the meta-analysis. Physician burnout was associated with an increased risk of patient safety incidents (OR, 1.96; 95% CI, 1.59-2.40), poorer quality of care due to low professionalism (OR, 2.31; 95% CI, 1.87-2.85), and reduced patient satisfaction (OR, 2.28; 95% CI, 1.42-3.68). The heterogeneity was high and the study quality was low to moderate. The links between burnout and low professionalism were larger in residents and early-career (≤5 years post residency) physicians compared with middle- and late-career physicians (Cohen Q = 7.27; P = .003). The reporting method of patient safety incidents and professionalism (physician-reported vs system-recorded) significantly influenced the main results (Cohen Q = 8.14; P = .007).

Conclusions and Relevance  This meta-analysis provides evidence that physician burnout may jeopardize patient care; reversal of this risk has to be viewed as a fundamental health care policy goal across the globe. Health care organizations are encouraged to invest in efforts to improve physician wellness, particularly for early-career physicians. The methods of recording patient care quality and safety outcomes require improvements to concisely capture the outcome of burnout on the performance of health care organizations.

Novartis links bonuses to ethics in bid to rebuild reputation

John Miller
Reuters
Originally posted September 17, 2018

Swiss drugmaker Novartis (NOVN.S) has revealed its employees only get a bonus if they meet or exceed expectations for ethical behavior as it seeks to address past shortcomings that have damaged its reputation.

Chief Executive Vas Narasimhan has made strengthening the Swiss drugmaker’s ethics culture a priority after costly bribery scandals or legal settlements in South Korea, China and the United States.

Employees now receive a 1, 2 or a 3 score on their values and behavior. Receiving a 2, which Novartis said denotes meeting expectations, or a 3, for “role model” behavior, would make them eligible for a bonus of up to 35 percent of their total compensation.

Novartis said it began the scoring system in 2016 but details have not been widely reported. Company officials outlined the system on Monday on a call about its ethics efforts with analysts and journalists.

The info is here.

When You Fear Your Company Has Forgotten Its Principles

Sue Shellenbarger
The Wall Street Journal
Originally published September 17, 2018

Here is an excerpt:

People who object on principle to their employers’ conduct face many obstacles. One is the bystander effect—people’s reluctance to intervene against wrongdoing when others are present and witnessing it too, Dr. Grant says. Ask yourself in such cases, “If no one acted here, what would be the consequences?” he says. While most people think first about potential damage to their reputation and relationships, the long-term effects could be worse, he says.

Be careful not to argue too passionately for the changes you want, Dr. Grant says. Show respect for others’ viewpoint, and acknowledge the flaws in your argument to show you’ve thought it through carefully.

Be open about your concerns, says Jonah Sachs, an Oakland, Calif., speaker and author of “Unsafe Thinking,” a book on creative risk-taking. People who complain in secret are more likely to make enemies and be seen as disloyal, compared with those who resist in the open, research shows.

Successful change-makers tend to frame proposed changes as benefiting the entire company and its employees and customers, rather than just themselves, Mr. Sachs says. He cites a former executive at a retail drug chain who helped persuade top management to stop selling cigarettes in its stores. While the move tracked with the company’s health-focused mission, the executive strengthened her case by correctly predicting that it would attract more health-minded customers.

The info is here.

Urban Meyer, Ohio State Football, and How Leaders Ignore Unethical Behavior

David Mayer
Harvard Business Review
Originally posted September 4, 2018

Here is an excerpt:

A sizable literature in management and psychology helps us understand how people become susceptible to moral biases and make choices that are inconsistent with their values and the values of their organizations. Reading the report with that lens can help leaders better understand the biases that get in the way of ethical conduct and ethical organizations.

Performance over principles. One number may surpass all other details in this case: 90%. That’s the percentage of games the team has won under Meyer as head coach since he joined Ohio State in 2012. Psychological research shows that in almost every area of life, being moral is weighted as more important than being competent. However, in competitive environments such as work and sports, the classic findings flip: competence is prized over character. Although the report does not mention anything about the team’s performance or the resulting financial and reputational benefits of winning, the program’s success may have crowded out concerns over the allegations against Smith and about the many other problematic behaviors he showed.

Unspoken values. Another factor that can increase the likelihood of making unethical decisions is the absence of language around values. Classic research in organizations has found that leaders tend to be reluctant to use “moral language.” For example, leaders are more likely to talk about deadlines, objectives, and effectiveness than values such as integrity, respect, and compassion. Over time, this can license unethical conduct.

The info is here.

A Two-Factor Model of Ethical Culture

Caterina Bulgarella
ethicalsystems.org

Making Progress in the Field of Business Ethics

Over the past 15 years, behavioral science has provided practitioners with a uniquely insightful
perspective on the organizational elements companies need to focus on to build an ethical culture.
Pieced together, this research can be used to address the growing challenges business must tackle
today.

Faced with unprecedented complexity and rapid change, more and more organizations are feeling the
limitations of an old-fashioned approach to ethics. In this new landscape, the importance of a proactive ethical stance has become increasingly clear. Not only is a strong focus on business integrity likely to reduce the costs of misconduct, but it can afford companies a solid corporate reputation, genuine employee compliance, robust governance, and even increased profitability.

The need for a smarter, deeper, and more holistic approach to ethical conduct is also strengthened by
the inherent complexity of human behavior. As research continues to shed light on the factors that
undermine people’s ability to ‘do the right thing,’ we are reminded of how difficult it is to solve for
ethics without addressing the larger challenge of organizational culture.

The components that shape the culture of an organization exercise a constant and unrelenting influence on how employees process information, make decisions, and, ultimately, respond to ethical dilemmas.  This is why, in order to help business achieve a deeper and more systematic ethical focus, we must understand the ingredients that make up an ethical culture.

The information is here.

Getting Ethics Training Right for Leaders and Employees

Deloitte
The Wall Street Journal
Originally posted April 9, 2018

Here is an excerpt:

Ethics training has needed a serious redesign for some time, and we are seeing three changes to make training more effective. First, many organizations recognize that compliance training is not enough. Simply knowing the rules and how to call the ethics helpline does not necessarily mean employees will raise their voice when they see ethical issues in the workplace. Even if employees want to say something they often hesitate, worried that they may not be heard, or even worse, that voicing may lead to formal or informal retaliation. Overcoming this hesitation requires training to help employees learn how to voice their values with in-person, experiential practice in everyday workplace situations. More and more organizations are investing in this training, as a way to simultaneously support employees, reduce risk and proactively reshape their culture.

Another significant change in ethics training is a focus on helping senior leaders consider how their own ethical leadership shapes the culture. This requires leaders to examine the signals they send in their everyday behaviors, and how these signals make employees feel safe to voice ideas and concerns. In my training sessions with senior leaders, we use exercises that help them identify the leadership behaviors that create such trust, and those that may be counter-productive. We then redesign the everyday processes, such as the weekly meeting or decision-making models, that encourage voice and explicitly elevate ethical concerns.

Third, more organizations are seeing the connection between ethics and greater sense of purpose in the workplace. Employee engagement, performance and retention often increases when employees feel they are contributing something beyond profit creation. Ethics training can help employees see this connection and practice the so-called giver strategies that help others, their organizations, and their own careers at the same time.

The article is here.

The Associations between Ethical Organizational Culture,Burnout, and Engagement: A Multilevel Study

Mari Huhtala, Asko Tolvanen, Saija Mauno, and Taru Feldt
J Bus Psychol
DOI 10.1007/s10869-014-9369-2

Abstract/Purpose

Ethical culture is a specific form of organizational culture (including values and systems that can promote ethical behavior), and as such a socially constructed phenomenon. However, no previous studies have investigated the degree to which employees’ perceptions of their organization’s ethical culture are shared within work units (departments), which was the first aim of this study. In addition, we studied the associations between ethical culture and occupational well-being (i.e., burnout and work engagement) at both the individual and work-unit levels.

Design/Methodology/Approach

The questionnaire data were gathered from 2,146 respondents with various occupations in 245 different work units in one public sector organization. Ethical organizational culture was measured with the corporate ethical virtues scale, including eight sub-dimensions.

Findings

Multilevel structural equation modeling showed that 12–27 % of the total variance regarding the dimensions of ethical culture was explained by departmental homogeneity (shared experiences). At both the within and between levels, higher perceptions of ethical culture associated with lower burnout and higher work engagement.

Implications

The results suggest that organizations should support ethical practices at the work-unit level, to enhance work engagement, and should also pay special attention to work units with a low ethical culture because these work environments can expose employees to burnout.

Originality/Value

This is one of the first studies to find evidence of an association between shared experiences of ethical culture and collective feelings of both burnout and work engagement.

A copy of the article is here.

Do It Well and Do It Right: The Impact of Service Climate and Ethical Climate on Business Performance and theBoundary Conditions

Jiang, K., Hu, J., Hong, Y., Liao, H., & Liu, S.
Journal of Applied Psychology. Advance online publication.

Abstract

Prior research has demonstrated that service climate can enhance unit performance by guiding employees’ service behavior to satisfy customers. Extending this literature, we identified ethical climate toward customers as another indispensable organizational climate in service contexts and examined how and when service climate operates in conjunction with ethical climate to enhance business performance of service units. Based on data collected in 2 phases over 6 months from multiple sources of 196 movie theaters, we found that service climate and ethical climate had disparate impacts on business performance, operationalized as an index of customer attendance rate and operating income per labor hour, by enhancing service behavior and reducing unethical behavior, respectively. Furthermore, we found that service behavior and unethical behavior interacted to affect business performance, in such a way that service behavior was more positively related to business performance when unethical behavior was low than when it was high. This interactive effect between service and unethical behaviors was further strengthened by high market turbulence and competitive intensity. These findings provide new insight into theoretical development of service management and offer practical implications about how to maximize business performance of service units by managing organizational climates and employee behaviors synergistically.

The article is here.

Relaxing moral reasoning to win: How organizational identification relates to unethical pro-organizational behavior.

Chen, Mo; Chen, Chao C.; Sheldon, Oliver J.
Journal of Applied Psychology, Vol 101(8), Aug 2016, 1082-1096.

Abstract

Drawing on social identity theory and social–cognitive theory, we hypothesize that organizational identification predicts unethical pro-organizational behavior (UPB) through the mediation of moral disengagement. We further propose that competitive interorganizational relations enhance the hypothesized relationships. Three studies conducted in China and the United States using both survey and vignette methodologies provided convergent support for our model. Study 1 revealed that higher organizational identifiers engaged in more UPB, and that this effect was mediated by moral disengagement. Study 2 found that organizational identification once again predicted UPB through the mediation of moral disengagement, and that the mediation relationship was stronger when employees perceived a higher level of industry competition. Finally, Study 3 replicated the above findings using a vignette experiment to provide stronger evidence of causality. Theoretical and practical implications are discussed.

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Managerial Implications Section

In addition to these theoretical contributions, it is also worth briefly touching upon some implications of the present research for managerial practice. Unethical behaviors have proven costly for organizations (Cialdini et al., 2004), especially those behaviors conducted in the name of the organization, which are more likely to undermine stakeholders' organizational trust or even cause the collapse of an organization. In view of the dark side of organizational identification, managers should be aware of blind allegiance and loyalty to the organization among their employees and instead emphasize the importance of social responsibility and caring for all stakeholders. The linkage between organizational identification and moral disengagement we document here suggests that loyal organizational members are under greater pressure to relax their moral reasoning to execute their citizenship behavior, especially when stakes are high in a competitive environment. To counterbalance the tendency toward moral disengagement, organizations and managers need to clearly highlight the importance of hyper ethical values in organizational policies and practices and integrate such ethical standards into managerial decision-making. At the same time, organizations should strive to create a culture of social responsibility so as to reduce UPB (May et al., 2015) and reinforce ethical pro-organizational behavior.

The article is here.

A Code of Ethics for Health Care Ethics Consultants

Anita J. Tarzian & Lucia D. Wocial
American Journal of Bioethics 15 (5):38-51 (2015)

Abstract

For decades a debate has played out in the literature about who bioethicists are, what they do, whether they can be considered professionals qua bioethicists, and, if so, what professional responsibilities they are called to uphold. Health care ethics consultants are bioethicists who work in health care settings. They have been seeking guidance documents that speak to their special relationships/duties toward those they serve. By approving a Code of Ethics and Professional Responsibilities for Health Care Ethics Consultants, the American Society for Bioethics and Humanities (ASBH) has moved the professionalization debate forward in a significant way. This first code of ethics focuses on individuals who provide health care ethics consultation (HCEC) in clinical settings. The evolution of the code's development, implications for the field of HCEC and bioethics, and considerations for future directions are presented here.

The entire paper is here.

Measuring the Return on Character

Harvard Business Review
April 2015

Here is an excerpt:

Character is a subjective trait that might seem to defy quantification. To measure it, KRW cofounder Fred Kiel and his colleagues began by sifting through the anthropologist Donald Brown’s classic inventory of about 500 behaviors and characteristics that are recognized and displayed in all human societies. Drawing on that list, they identified four moral principles—integrity, responsibility, forgiveness, and compassion—as universal. Then they sent anonymous surveys to employees at 84 U.S. companies and nonprofits, asking, among other things, how consistently their CEOs and management teams embodied the four principles. They also interviewed many of the executives and analyzed the organizations’ financial results. When financial data was unavailable, leaders’ results were excluded.

The entire article is here.

Ethical Breakdowns

Max H. Bazerman and Ann E. Tenbrunsel

Harvard Business Review

Originally published in April 2011

Here is an excerpt:

Motivated Blindness

It’s well documented that people see what they want to see and easily miss contradictory information when it’s in their interest to remain ignorant—a psychological phenomenon known as motivated blindness. This bias applies dramatically with respect to unethical behavior. At Ford the senior-most executives involved in the decision to rush the flawed Pinto into production not only seemed unable to clearly see the ethical dimensions of their own decision but failed to recognize the unethical behavior of the subordinates who implemented it.

Let’s return to the 2008 financial collapse, in which motivated blindness contributed to some bad decision making. The “independent” credit rating agencies that famously gave AAA ratings to collateralized mortgage securities of demonstrably low quality helped build a house of cards that ultimately came crashing down, driving a wave of foreclosures that pushed thousands of people out of their homes. Why did the agencies vouch for those risky securities?

Part of the answer lies in powerful conflicts of interest that helped blind them to their own unethical behavior and that of the companies they rated. The agencies’ purpose is to provide stakeholders with an objective determination of the creditworthiness of financial institutions and the debt instruments they sell.

The entire article is here.

Whistleblowing and the Bioethicist’s Public Obligations

By D. Robert MacDougall
Cambridge Quarterly of Healthcare Ethics / Volume 23 / Issue 04 / October 2014, pp 431-442

Abstract:

Bioethicists are sometimes thought to have heightened obligations by virtue of the fact that their professional role addresses ethics or morals. For this reason it has been argued that bioethicists ought to “whistleblow”—that is, publicly expose the wrongful or potentially harmful activities of their employer—more often than do other kinds of employees. This article argues that bioethicists do indeed have a heightened obligation to whistleblow, but not because bioethicists have heightened moral obligations in general. Rather, the special duties of bioethicists to act as whistleblowers are best understood by examining the nature of the ethical dilemma typically encountered by private employees and showing why bioethicists do not encounter this dilemma in the same way. Whistleblowing is usually understood as a moral dilemma involving conflicting duties to two parties: the public and a private employer. However, this article argues that this way of understanding whistleblowing has the implication that professions whose members identify their employer as the public—such as government employees or public servants—cannot consider whistleblowing a moral dilemma, because obligations are ultimately owed to only one party: the public. The article contends that bioethicists—even when privately employed—are similar to government employees in the sense that they do not have obligations to defer to the judgments of those with private interests. Consequently, bioethicists may be considered to have a special duty to whistleblow, although for different reasons than those usually cited.

The entire article is here, behind a paywall.