In the last thirty years institutions have become more central to the delivery of health care than have physicians in private practice. Increasing numbers of physicians practise in large multispecialty groups and complex healthcare organisations (HCOs). As medicine becomes more specialised and its technology more expensive, these services and technologies are being merged under one roof so that they can be utilised in the most efficient way.
Institutionalising medicine means more, however, than moving doctors’ offices into hospital buildings. First, the hospital has more in common with other organisations and bureaucracies than it has with the traditional doctor’s office: it is hierarchically organised, has a complex division of labour, and its practices and decision making processes rely largely on rules and policies.1 Health care today is practiced by teams, not only by individual physicians. It includes health services research, mechanisms for quality review, complex networks of informational systems, logistical strategies for the coordinated use of expensive and institutionally based technologies, and it involves multiple levels of management. Health care involves several disciplines and professions beyond medicine. Physicians are but one group of professionals—albeit an essential one—who serve the goals of the healthcare organisation.
Clinical ethics is, traditionally, oriented toward the individual doctor and her patient, focusing on their rights, their actions, and how they justify their treatment decisions. Evolving as the ethics of this particular professional group, it assumes that there are two main participants only—the doctor and the patient—and that they decide jointly and in private on the course of medical treatment. Problems that arise therefore in the doctor/patient relationship are solved on a case by case basis, although occasionally with the help of an ethics consultation service.
Because of its focus on individual agency, clinical ethics fails to recognise the effects of the organisational culture in which health care is delivered, which include the effects of that culture’s informal rules, and, more importantly, the effects of its beliefs and assumptions regarding ethical conduct and ethical decision making. Recent research in organisation theory and business ethics has focused on trying to understand the factors influencing ethical conduct in organisations. Issues that promote unethical behaviour are ambiguity among staff about organisational priorities, the lack of forums for discussing the ethical dimension of behaviours, and hierarchical power structures that prevent horizontal relationships. Unethical conduct can be reduced by leaders who encourage and model ethical behaviour, reward ethical conduct and discipline unethical conduct, and emphasise treating employees fairly rather than strictly obeying authority.2,3 Organisational ethics suggest processes that promote the organisational culture that supports ethical decision making and ethical behaviour. Less attention has been given, however, to the question: how should healthcare organisations deal with moral disagreement about medical practices?
Second, institutionalising medicine changes the setting of medical practice from private to public. The HCO is accountable for how it interacts with its physicians, patients, and multiple other stakeholders: insurers, employees, investors, and the wider community of the public. Because many people interact in a healthcare organisation and mutually influence one another and because their multiple interactions are governed by rules, the HCO is a "semipublic" place. This semipublic status bears importantly on the way the HCO should respond to moral disagreement. Unlike the individual doctor’s office, where the doctor and patient may reach a private agreement within the limits of the law, the HCO must take a public stand on controversial medical practices and hotly debated ethical issues.
In the absence of a process that generates common agreement in terms of a policy, one must assume that in the HCO’s view morally controversial medical decisions are best handled by the individual healthcare providers. Avoiding taking such a position and lacking an explicit policy is, in itself, taking a stand and must be justified. Because policies guide individual action and thereby constitute the collective action of the organisation, they play an important role in modelling the interaction of the HCO with its different stakeholders.4 Therefore HCOs must carefully consider their policies and rules so as to make them justifiable. This is especially critical for policies that address controversial medical practices about which reasonable people disagree such as abortion, organ donation, or palliative sedation.
Traditional clinical ethics, with its concept of the private doctor/patient relationship, does not address the question of the HCO’s semipublic role and how it should respond to moral disagreement about controversial medical practices. Therefore, political and administrative ethics, rather than merely clinical ethics, should inform our understanding of ethical problems, behaviours, and obligations in HCOs.
I shall argue that a consensus building process leading to hospital wide policies is the better alternative to individual decision making because it respects the autonomy of all parties involved and better ensures quality, fairness, and an efficient decision making process.