I argue that the adequate response of a HCO to moral disagreement is a process of consensus building that leads to hospital wide policies, because such a process better respects the autonomy of all parties involved than individual decision making, and better ensures the quality, fairness, and efficiency of the decision making process.
Policy writing for morally controversial medical practices differs from policy writing for standard medical practices, because it resembles more closely a political process than an authoritarian directive on standard medical care. Such a process therefore has to meet the five additional requirements discussed above, which are primarily procedural, in order to claim legitimate authority over the actions of individual members of the organisation. The task of policy writing must be as concerned with the process of reaching consensus by open deliberation as with the actual outcome of the process. This is to say that different solutions can be equally reasonable, depending on how much weight the deliberative process gives to any of the substantive principles that reflect the obligations of a HCO: care for the sick; treat your employees with respect; act in AQ A public spirit, and use resources reasonably.
Many thanks for helpful comments and discussion of this material to Dennis F Thompson, Anne Mills, Sandra Badin, K Robin Pierce, and members of the Faculty Seminar of the Center for Ethics and the Professions at Harvard University. I am also most grateful to James Sabin, Judy Johnson, and John Emans for providing me with the opportunity to observe the work of their organisational ethics programmes in practice and to Jean McVeigh for her generous support in editing the latest drafts of this paper.
Funding: this work has been generously funded by the Edmond J Safra foundation.