SFGH Ethics Committee Discusses Operationalizing Justice

SFGH Ethics Committee
December 23, 2013
Kate Michi Ettinger, JD
Operationalizing Justice:
From Clinical to Organizational Ethics

Operationalizing Justice: From Clinical to Organizational Ethics
 No financial conflicts of interest
Disclaimers
Trained in law, but not practicing attorney; nothing
presented is intended as legal advice.
Disclosures

Baseline
Raise a hand if in the last 6months you have participated in
one clinical situation, in which you felt the care provided to a
patient was not optimal.
And, raise the other hand if that sub-optimal situation was
due to an institutional issue at the systems level (resource
constraints, stafﬁng, cross department issues, cross
institutional issues, costs)- i.e. beyond the clinicians involved.
Stand up if it has happened more than once in the last 6
months. Stay standing if it has happened in the last month.

Brainstorm
What are organizational issues that you have
encountered that seem ethically problematic?

Examples
• decision to close a service (e.g. asthma program)
due to budget concerns that service closure
impacts access to care
• weighing decision about innovative program to
improve care delivery versus budget concerns
• how to allocate scare resources (ICU) and
expensive resources (dialysis)
• addressing interservice transfers and the costs
associated with prolonged hospitalizations

Examples
• the “uninvited” consultant
• disclosure of medical errors
• management of patients with disruptive behavior
• donation after cardiac death
• medical futility

Goals
How do organizational ethics and clinical
ethics differ?
What models have other institutions used to
address organizational ethical issues?
How might we approach an organizational
ethics issue at our hospital?

How are organizational ethics and
clinical ethics different?

Guides how clinicians use their professional
power and governs the imbalance in power
Clinician/Team
- Pt
Relationship

Clinical Ethics Example
Mrs. K is a 82 year old nursing home resident with
dementia, renal disease, and limited functional
ability. Within the last month, Mrs. K has been
admitted 4 times for altered mental status. Each
time, after hydration and care for 1-2 days, she
regains alert status and is discharged. A full work up
has reveals nothing acute. These episodes appear to
be caused by difficulty swallowing and dehydration.
On this 4th hospitalization,
the Ethics Committee is consulted.

Principles for Analysis:
What does patient want? Respect for persons
What will promote this patient's well-being? Beneficence
What can we do to avoid harming this patient? Non-maleficence
Justice
Clinical Ethics Consult

Ethical Guidelines
Clinical Ethics Analysis: Justice ?
A member of the team expresses this view
during the consult meeting:
Isn’t this patient's use of expensive resources
(ED, hospitalizations) an unjust allocation of
resources and ethically wrong?

Clinical Ethics Analysis: Justice
This Pt's use of expensive resources is an
unjust allocation of resources and thus,
ethically inappropriate.
Justice is not applied at the individual level.
Making decisions about this individual’s
care based upon resource allocation
is not ethically appropriate.

So, what about justice?

“Treating similarly situated patients similarly”
What does this mean?
Justice Principle
Goals
Fair distribution of the beneﬁts/
burdens of societal goods
Substantive
Procedural

“Treating similarly situated patients similarly”
Whose view of Justice?
Societal or defined population (within a dept, at this hospital, in a county)
Who is “treating”?
Physician/Team, Organization, Payer
How do you define “similarly situated”?
Disease condition v. current status; personal factors
How does one assess “treating similarly”?
Based upon clinical diagnosis or other factors
Access may inform whether pts are treated similarly

Operationalizing Justice
Key Considerations
Systematic approach
Consistent, Fair
Principled distribution of burdens/beneﬁts
Transparency
Explicit consideration of competing interests
Well-reasoned justiﬁcation for decisions
Participatory processes
Inclusive of relevant, diverse stakeholders
Transparent

Historical Care Paradigm
Hospital as Silent Partner in Care Delivery

Hospital as Active Player in the Care Paradigm
Organization
to Patients
Relationship

Hospital is actor on care team impacting
Clinician-Patient Relationship
Organization
to Providers
Relationship

Organization
to Patients
Relationship
Clinical Team -
Pt Relationship
Organization
to Providers
Relationship

Ethical Landscape
Clinical Ethics
Applies to MD/Team
Governs relationship
Clinician-Patient
Principles
Respect for persons
Beneficence
Non-maleficence
Organizational Ethics
Applies to:
Organization action
Clinician action
Governs relationship:
Organization to MD/Team
Organization to Patients
Principles
Clinical ethics ?
Virtue ethics ?
Business ethics?
Public health ethics?
Other values?

Three Approaches

System Approach
VA: Integrated Ethics Program
Systems-focused model
to promote and improve ethical practices in health care
Goal: Ethics quality
“practices throughout the organization are consistent with
widely accepted ethical standards, norms or expectations
for a health care organization and its staff ”
Targets: Ethics quality gaps
Framework: Levels of ethics quality

Systemic Approach (VA)
Decisions & Actions

Decisions & Actions
Systems & Processes

Decisions & Actions
Systems & Processes
Environment & Culture

Decisions & Actions
Systems & Processes
Ethics Consultation

Decisions & Actions
Systems & Processes
 Ethics Consultation
Preventative Ethics

Decisions & Actions
Systems & Processes
Ethics Consultation
Preventative Ethics
Ethical Leadership

Ethics Consultation
Decisions & actions
CASES approach
 Clarify the request
 Assemble info
 Synthesize info
 Explain synthesis
 Support consult

Ethics Consultation
Decisions & actions
Preventative Ethics
Systems & Processes
CASES approach
ISSUES approach
Identify Issue
Study Issue
Select Strategy
Undertake Plan
Evaluate & Adjust
Sustain & Spread

Ethics Consultation
Decisions & actions
Preventative Ethics
Systems & Processes
Ethical Leadership
CASES approach
ISSUES approach
Leadership Compass
Demonstrate Ethics as Priority
Communicate Expectations
Practice Ethical Decision Making
Support Local IE Program

What does ethics have in
common with chocolate?

Leadership
Compass
Ethics Consultation
Decisions & actions
Preventative Ethics
Systems & Processes
Ethical Leadership
CASES
ISSUES
VA: Integrated Ethics Program

System Approach (VA)
Features
Integrated care delivery system
Multiple facilities
Mandated model implemented locally
Integrated Ethics
Systems-focused model
Ethics quality
Process-driven
Values-based decision making

Institutional Approach
Montefiore Organizational Ethics
 Goals:
 To reconcile tensions for decisions with
competing business and clinical interests
 To ground and guide the approach for
business decisions that had clinical implications

Decision Making Model:
• Identify the problem
• Identify the key players
• Diagnose the situation
• Analyze the options
• Ethical implications of the options
• Resolution of the problem
• Implementation

Montefiore Organizational Ethics Principles
I. Principle of Protecting Professional Integrity
Health care organizations have a moral obligation to protect the
integrity of clinical decision making and the physician-patient
relationship, irrespective of the means by which the organization
and their physicians are compensated or share risk.

II. Principle of Ethics Audit
Health care organizations have a moral obligation
to conduct an “ethics impact audit” of all decisions
affecting the allocation of health care services
to particular patient populations, including the
opportunity costs of those decisions.
These decisions should be defensible as a
reasonable way of meeting stewardship obligations,
and the reasons for these decisions should be
publicly accessible to the appropriate parties

Issues addressed:
 Allocating critical care resources
 Justice and access to unreimbursed therapies
 Guidelines for transferring patients between services
 Decision making protocol for the patient alone
 Confidentiality and privacy in the era of IT
 Physician autonomy and the uninvited consultant

Montefiore Organizational Ethics
Features
Charitable Hospital
Mixed Payer System
Administratively supported-driven model
OE Program
Subcommittee of the Ethics Committee
Process: Decision Making Model (Stakeholder Approach)
Principles: Protecting Professional Integrity/ Ethics Audit

Harvard-Pilgrim Organizational Ethics
Features
NP Health Insurance Company
Administratively driven model
OE Program
To promote increased organizational skill at identifying ethical
dimensions of policy/operations/budget decisions
Ethics Advisory Group (diverse stakeholders)
Consultative/decision support
Process:
Customer presents problem: Case Study & Analysis
EAG reviews & discusses: publish report
Principles:
Provide care with compassion, treat employees with respect,
act in a public spirit, spend resources reasonably

Pittsburgh VA (2006)
Features
Federal hospital (regional facility)
Public accountability
Administratively initiated, employee led
Organizational Ethics Issue: MRSA
Principle: Avoidable death is impermissible (do no harm)
Current metrics permit avoidable death
Public Health PD Innovators: Jerry & Monique Sternin and Jon Lloyd, MD
Method/Process: Positive Deviance
Institutional/Issue Approach

Pittsburgh VA (2006)
Positive Deviance Invitation & Implementation
Define the problem
Determine common practices
Discover the positive deviants
Design activities to expand PD solution
Examples of Change
Cross functional services
Techs
Janitors
Chaplains
Seemingly Intractable Environments: Nursing Home
Institutional/Issue Approach

Issue Approach
Contra Costa County
Features
Safety net hospital
Public accountability
Ethics committee driven
Organizational Ethics: Subgroup of the ethics committee
Process: Study group: Radical Respect, Commitment to Learning, Justice
Principles: Virtue ethics: integrity, respect, compassion, humility, empathy

Issue Approach
 Contra Costa County
Issues addressed:
 Disclosure of medical errors & adverse events
 Medical futility
 Determination of cardiac death
 Decisions for the patient alone
 Management of disruptive pt

Organizational Ethics Approaches
System-wide
 Multi-facility, addresses systems actions at all levels
 Process driven
 Values based decision making
Institutional
 Hospital, addresses organization actions
 Principle driven - Stakeholder included decision making model
 Organizational ethical principles
Issue Approach
• Ethics committee driven, addresses specific actions
• Issue focused study group
• Virtue ethics principles

Facilitators of Success
 Galvanizing issues that elicit organizational concern
 Facilitator with ethics and organizational skills
 Including key stakeholders in deliberations
 Radical respect with a commitment to learning
 Passionate leadership

Key Considerations Systematic approach
Consistency
Fair
Principled distribution of burdens/beneﬁts
Transparency
Explicit consideration of competing interests
Well-reasoned justiﬁcation for decisions
Participatory processes
Inclusive of relevant, diverse stakeholders
Transparent

1. Understand the issue/problem
2. Talk to stakeholders
3. Identify Options:
-- Brainstorm possibilities
-- Explore ethical dimensions of options
4. Develop Proposal:
-- Integrated solution that explains rationale
-- Review proposal with stakeholders for input
-- Refine based on stakeholder feedback
5. Implement
6. Assess outcome/impact
Suggested Framework

Bibliography
Beauchamp, TL and Childress, JF. Principles of Biomedical Ethics, 5th Ed. Oxford
University Press, 2001.
Blustein, J. Farber Post, L. Dubler, N. Ethics for Health Care Organizations. United
Hospital Fund Press, 2003.
Farber-Post, L. Blustein, J. Dubler, N. Handbook for Health Care Ethics Committees,
Johns Hopkins University Press, 2007.
National Center for Ethics in Health Care, Veterans Health Administration, Integrated
Ethics: Improving Ethics Quality in Health Care.
Sabin, J and Cochran, D. Confronting Trade-offs in Health Care: Harvard- Pilgrim Health
Care’s Organizational Ethics Program, Health Affairs: Jul/Aug 2007. vol.26, Iss.
4: 1129-1134.

Thank You
Stay in touch!
Kate Michi Ettinger
Daily Paper.li on Bioethics
@k8ethics (Twitter)
www.muralinstitute.org

SFGH Ethics Committee Discusses Operationalizing Justice

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