Do you want us to hide information or release information? Make up your mind.

Moral intelligence is the thoughtful application of objective but not absolute modern-day ethical principles to specific fact situations, in order to predict possible long-range effects of our actions on ourselves and others. (1)

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Being morally intelligent does not come naturally. It is a special application of uncommon sense--critical thinking--a skill that must be practiced. (2)

For example, sometimes the public insists that hospitals hide information and other times the public demands that hospitals share information. If we think that is an inconsistent double standard unfair to hospitals, then we are not yet morally intelligent.

Frank Weller, vice president of medical affairs at Central Medical Center, is pondering two matters on his desk that must be dealt with today.

First he must catch Charlie Denway, a dependable and cooperative surgeon not interested in organizational affairs, before he leaves on vacation. A nurse has reported that Denway inadvertently violated Health Insurance Portability and Accountability Act (HIPPA) regulations; he discussed a patient's case with the patient's best friend without first obtaining the patient's permission to do so.

Weller is well aware that HIPAA is a perfect example of well-meaning regulation gone berserk. Weller's wife is a chronically ill heart patient who sees her doctor every two weeks. The doctor's desk clerk always greets Weller and his wife as though she has never seen them before. She always asks the same questions, including: "If someone calls and asks for you, may we tell them you are here?"

Weller wants to say, "Absolutely not, because we are running from the law." But the worst he has ever done is, "You know, they've repealed the HIPAA regs ..."

Weller chuckles, then sobers. This is not really funny. Denway must be made to understand that his behavior is a good fit for the time when physicians following professional instincts were an asset to the hospital, but in today's world such behavior must be quickly squelched.

Then, Weller must prepare for the lunch meeting with Bill Moncrief, an excellent internist and new member of the hospital's board of directors. Like Denway, Moncrief's background does not include opportunities to understand the difference between clinical-speak and organization-speak. And, Moncrief has made a mistake that he won't make again after Weller talks to him. This matter also involves the need to keep information secret.

A board member golfing partner of Moncrief's has complained to the CEO that Moncrief openly discusses board business with colleagues on the golf course and on other occasions as well. The CEO has asked Weller to re-orient Moncrief to the board's confidentiality policies, especially reminding him that loose lips sink ships. That is, Moncrief might accidentally reveal secret information to a public watchdog or an investigative reporter.

Weller leans back in his chair and, in a rare reflective moment, muses about the ironic juxtaposition of these two tasks. The talk with Denway relates to the public's insistence that hospitals hide information; the talk with Moncrief relates to public demands that hospitals share information.

Isn't that inconsistency unfair? Aren't hospitals being whipsawed? Shouldn't we complain about being made to meet a double standard?

Ethical dilemma 

Actually, public demands that we sometimes hide information and sometimes share information are consistent and fair. Certainly that conclusion is counter-intuitive, meaning contrary to what common sense tells us.

To understand what's going on here we must exercise uncommon sense, moral intelligence, to dig deep and recognize why inconsistent behavior is sometimes necessary to achieve ethical consistency. The fact is we are not truly morally intelligent, indeed we are ethically immature, until we recognize that common sense sometimes misleads us. Now that you are aware of that, you will see examples everywhere.

Uncommon sense informs us that there are two keys to understanding the issue under discussion.

1. First, ethical consistency does not mean always doing the same thing. Rather, it means consistently serving important ethical principles. This realization has allowed modern day ethicists to resolve the traditional debate between objectivists and subjectivists. Objectivists insist that there are absolute ethical values that allow no exceptions. Subjectivists argue that the same size shoe does not fit every foot, that ethical principles must be bent and shaped depending on the situation. It turns out neither extreme view is correct. Rather, there are objective truths that apply differently to different situations. Truth is an absolute value, but if Anne Frank were hiding in your attic the most ethical thing to do might be to tell the Nazis that she is not.

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2. Second, in difficult situations it is often impossible to equally serve each and every important ethical principle. In most ethical dilemmas one ethical principle trumps all other ethical principles. In the Anne Frank example, preserving a human life trumps telling the truth.

If traditional philosophy-based ethicists had admitted these realities, if they had allowed necessary flexibility, then they would still be hot properties. By stubbornly defending something that does not exist, absolute truth, they relegated themselves to becoming important but obsolete historical footnotes.

In the situation we are discussing, which ethical principle trumps others that are important but secondary?

At first glance, the answer might seem to be privacy. Ethical principles are derived from three sources: reason, experience and tradition. Privacy is a traditional human right, currently under siege because of modern technology that makes eavesdropping on phone calls, text messages and e-mail a simple walk in the park.

Aren't the most important considerations in the matter under discussion the right of individuals to keep personal information private and the right of hospitals to keep corporate information private? After all, it is hard to imagine a world without privacy; go ahead, try.

What could be more important than privacy? In some situations, nothing. However, in the matter we are discussing, on a scale of 1 to 10 privacy is only a 9. The ethical principle that trumps all others, the one that is a 9.9, is trustworthiness.

The public must trust us to use personal medical information discretely and honestly. This information must be collected in the interest of providing dependable medical care to sick people and correctly tailored health care maintenance services to the healthy, and for related purposes such as billing and developing epidemiological information. Period.

Any other use of personal medical information is a betrayal of public trust. Any short-term gain, such as revenue from secretly selling names and addresses to people who buy mailing lists, pales in comparison to the long-term loss of public trust. Trust is like a building in that it takes months, even years, to build but can be torn down in a single day. Trust is not like a building in that buildings can be rebuilt; trust often cannot be rebuilt.

Public information

The public is also entitled to valid and reliable information concerning our past performance so people can be sure it is safe to place their lives and well-being in our hands. What a sticky wicket this is.

How much of what kinds of information is the public entitled to see? Do we even know which information would truly predict the probable future reliability of this hospital, this long-term care facility, this group of health care professionals?

Furthermore, can't demands for releasing information reach ridiculous extremes? At one time, for example, there was a movement afoot to require physician report cards. That era was a distortion of the simple idea that it would be good to collect positive data confirming dependable physician performance in addition to confirming, or at least creating the illusion, that we are really good at identifying and weeding out bad doctors.

Physicians, by the way, successfully opposed the report card idea by using a variation of the old, "They don't have to so why should we?" argument. "Lawyers don't have to keep a won-lost record so why should we?"

Unfortunately, for several years we gamed requirements for good data instead of being morally intelligent. That is, we did not recognize the need to develop systems of handling sensitive information that are beneficial to us as well as to the public.

How could releasing performance information be of value to us? When the Institute of Medicine released a study concluding that up to 98,000 people die unnecessarily in hospitals each year, (3) we did not immediately react with counter data because we couldn't. We only issued valid and justifiable criticisms of the IOM study.

That is, we explained that just because a patient dies in the hospital that doesn't mean the hospital killed the patient, and that some instances labeled unnecessary deaths were questionable indeed. Unfortunately, our claims were considered even more questionable because the IOM had hard data and we didn't. Thus, we were painted with the same brush as corrupt corporate entities who, when outed, react with damage control.

Indeed, even when we try to use data to win public trust, we do it badly. The public is entitled to know that criteria for being named a Top Ten Hospital are often economic, such as highest return on investments or fewest FTEs per patient.

A token quality parameter, such as mortality rate, might be thrown in to disguise the fact that the Top Ten movement comes from marketing departments with little if any connection to actual day-to-day operations. Hospitals plaster the Top Ten designation on huge billboards. If people seeing the billboards want to conclude that the Top Ten hospital gives great care ... well, hey, that's what America is all about. Caveat emptor, baby.

Now you clearly understand the difference between old fashioned ethics, moral philosophy, and today's ethics, moral intelligence. Traditional moral philosophers foolishly pursued that which does not exist, absolute truth, and they foolishly insisted on the myth that absolute altruism, totally ignoring our own needs, is a good idea.

In contrast, moral intelligence requires flexibility and requires that we consider the long-range impact of our chosen actions on ourselves as well as on others.

Richard E. Thompson, MD, is former vice president of the Illinois Hospital Association, taught ethics at St. Petersburg College and Missouri State University, and is author of Think Before You Believe, Xlibris, 2005. He can be reached at [e-mail].

References

1. Thompson RE. "Look what's happened to health care ethics." The Physician Executive 32(2), March-April 2006.

2. Thompson RE. Think Before You Believe: Modern Day Myths, Questionable Claims, and Uncommon Sense. Xlibris, Philadelphia. www.xlibris.com, 2004.

3. Kohn LT, Corrigan JM, Donaldson MS. Institute of Medicine (U.S.) Committee on Quality of Health Care in America. To Err is Human: Building a Safer Health System. National Academy Press: Washington, DC. 2000.

By Richard E. Thompson, MD