Managed care's achilles heel: ethical immaturity. (Ethical Reasoning).

KEY CONCEPTS

* Ethical Reasoning

* Pragmatic Ethics

* Values

* Competitive Principles

* Reasonable Self Interest

MANY HEALTH CARE executives dismiss complaints about managed care as simply frustration caused by change. People's problems with the system," they say, "existed before and have nothing to do with managed care."' That comfortable position contains two thoughts, one correct and one incorrect. Problems with access, for instance, existed before managed care. But additional management and "gatekeeper" layers have worsened access to physicians.

The question that needs to be asked is not, "Are things worse since managed care?" but rather, "Are things any better? Are we delivering on our promises of improved access, more reasonable cost, and more dependable health care services?" Too many answer "No." One reason is the failure to use a powerful tool, ethical reasoning. Omitting it from the decision-making process is one form of ethical immaturity; failing to recognize the difference between ethical reasoning and making moral judgments is another.

What" acting ethically" really means

An individual's "ethics" might be written in a private document, titled "My Values: Guidelines for Living," or "My Personal Credo." But using these values when making important decisions should not be a monologue. Effective ethical reasoning requires discussing goals and possible methods from more than one point of view.

Organizations also put their beliefs to writing in mission or values statement. Far from being confidential, they are posted for all to see and are incorporated into marketing efforts. Sometimes these statements honestly reflect the "ethics" of individuals running the organization. Effective use of stated values requires a dialogue. Decision-making that is informed by an appreciation of all the stakeholders' interests results in intended benefits and avoids counterproductive consequences.

Why act ethically?

On the old TV show, Dallas, J.R Ewing was asked the secret to being such a good businessman. "Heck, there's no secret," he replied. "Once you give up integrity, everything else is a piece of cake."

One reason to act ethically is to stay out of trouble--the "compliance" mentality. Another is to reap delayed rewards or avoid eternal punishment--the religious argument. Altruism is often cited--an innate feeling of care for one's fellow man. But Adam Smith, the father of modern economic theory and a professor of moral philosophy, taught that altruism is often incompatible with the larger social good, especially when societies become complex. (2)

Running one's business on competitive (rather than altruistic) principles is ethical whenever greater efficiencies and economic growth enlarge the size of the pie for everyone. Reasonable self-interest is a perfectly acceptable reason to act ethically. Reasonable self-interest is good, not evil as some moralists might suggest.

Indeed, Aristotle said the same thing, but posted a warning: "The love of self is a feeling implanted by nature, but selfishness is rightly censured, because selfishness is not mere love of self, but the love of self in excess, like the miser's love of money." (3)

The pragmatic approach

The old philosophers and ethicists--Kant, Hume, Bentham, et al (4,5)--put out some good solutions to the problems of their time. But they treated their ideas as absolute rules--the only way to go in any and every situation. As decades and centuries passed, people discovered that these "rules" could not withstand all the "Yes, but, what if...?" questions. Nihilism emerged, characterized by subjectivism--there are no rules at all, just decide every question on its own merit as you see fit. That didn't work either.

Today's most helpful philosophers and ethicists (and to some degree, religionists) are pragmatists (6) who think that ethical reasoning takes place (8) within a context of forced options. For each issue, they believe they must fish or cut bait, sometimes even when information and time are limited. They would disabuse anyone of the notion that to be philosophical means to pontificate, be obscure, or delay action.

Philosophy and ethics in the executive suite are no longer strange and distracting concepts. In fact, CEOs who believe that pragmatic ethics are the enemy of "fast track" management may find themselves less in demand than those who satisfy long-range expectations and bring security and stability to organizations. For example, would gag orders" and the negative impact on managed care's public image ever have seen the light of day if we had known that reasonable self-interest required us to examine this decision more carefully?

A pragmatic approach treats considered judgments such as "promises should be kept" and "tell the truth" as accepted norms. Is over-promising in advertising a form of deception, or necessary in an intensely competitive environment? Is it ethical as long as we recognize and avoid a point at which exaggeration becomes deceitful falsification?"

In many respects, ethical reasoning is little more than "good business sense." It replaces nothing in the decision-making process, but adds a new dimension. When we raise implicit common sense to explicitly articulating our rationale, we can "publish" this rationale, certain that beginning "shared assumptions" are not our tunnel-vision perspective. In pragmatic ethical reasoning, we have a way to avoid erroneously selecting implementation methods. There is less devil in the details when clarity of purpose and agreed upon assumptions help us avoid the too common disappointment of striking off before we know exactly where we are going and ending up at an unintended destination.

Ethical immaturity

The absence of ethical reasoning is but one example of "ethical immaturity," term inspired by the work of John Abbott Worthley. (7) Other examples are:

* Equating moral judgment with the process of ethical reasoning

* Assuming that legal behavior is synonymous with ethical behavior

* Overstepping acceptable bounds of deceit in advertising

* Believing that confidentiality is an absolute rule

* Viewing compliance as synonymous with ethical behavior

* Confusing politically correct behavior with ethical behavior

A roadmap to achieve and practice ethical maturity

Managed care should adopt the ethic of reasonable profit generated by providing dependable health care services. (8, 9, 10)

But writing this global ethic into a values statement is an empty exercise if ethical reasoning does not become a consistent component of decision-making.

Figure 1 demonstrates the use of an Ethical Reasoning Guideline Worksheet. This is a roadmap to guide experimentation with ethical reasoning. The worksheet has been tested using several issues in addition to the example given (gag orders), such as in the area of credentialing and privileging practitioners. Try out the worksheet with an issue of your choosing.

The purpose of using this worksheet is to:

* Enlighten ourselves about whether a specific decision/action matches our statement of values/ethics

* Create a written rationale for our decision and action(s)

* Practice ethical reasoning

Conclusion

Managed care must practice the art of ethical reasoning if it is to silence its critics. Ethical maturity does not mean that executives and board members must develop a sudden interest in conversing with philosophers or in becoming ethicists. It simply means that the time has come to develop a basic understanding of pragmatic ethics, and to appreciate the value of adding ethical reasoning to the decision-making process in the executive suite and the board room. 1

Acknowledgement

The author gratefully acknowledges contributions to the article from his mentor, Paul B. Thompson, PhD, Joyce and Edward F. Brewer, Distinguished Professor of Applied Ethics, Purdue University, West Lafayette, Indiana.

Note

This article was originally presented as the Centennial Year Distinguished Guest Lecture at the School of Health Professions, Southwest Texas State University in San Marcos on November 5. 1998.

References

(1.) Emails to Richard E. Thompson, MD, in response to his article. "A Physician-Turned-Managed care consumer Shares his Experiences." ACPE News 2:2. February 15. 1999. p. 1.

(2.) Smith, Adam. The Wealth of Nations. (First published in 1776.) New York. New York: Modern Library. 1994.

(3.) Aristotle. Politics, Book II (trans. B. Jowett, intro. H.W.C. Davis). Oxford, England: Clarendon Press. 1905. pp. 62-63

(4.) Robinson, Dave and Garratt, Chris. Introducing Ethics. New York, New York: Totem Press. 1997.

(5.) Beauchamp, Tom and Childress, James. Principles of Biomedical Ethics. New York, New York and Oxford, England: Oxford University Press. 1994. p. 3 and 44.

(6.) Thompson, Paul B. "Pragmatism and Policy: The case of Water." chapter 9 (p. 187) in Environmental Pragmatism, E. Katz and A. Light. (Editors). New York. New York: Routledge Publishing Co., 1996.

(7.) Worthley, John Abbott. The Ethics of the Ordinary in Healthcare: concepts and cases. Chicago. Illinois: Health Administration Press, 1997.

(8.) Kassirer. Jerome. Managing Care: Should We Adopt a New Ethic? New England Journal of Medicine339:6, August 6,1998, p. 397.

(9.) Shortell, Stephen. et al. Physicians as Double Agents: Maintaining Trust in an Era of Multiple Accountabilities. Journal of the American Medical Association. 280:12, September 23/30, 1998. pp. 1102.1108.

(10.) Thompson, Richard. Sustainability as the Linchpin of Public Policy and Industry Initiatives in Health care. The Physician Executive 24:4, July/August. 1998, p. 52.

Richard E. Thompsan, MD, is a member of the American College of Physician Executives living in Dunedin, Florida and author of Health Care Reform as Social Change (ACPE, 1993). So You've Been Integrated, Now What? (ACPE. 1996). and Keys to Winning Physician Support 2nd Edition: Real Winners Don't Gag the Good Guys (ACPE. 1998). He can be reached by calling 727/789-4635 or via email at [e-mail].