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Business ethics in ethics committees?

Business Ethics in Ethics Committees?

A physical therapist employed at a physician-owned therapy service became distressed when the owner, an orthopedic surgeon, required the therapist to continue care for a patient beyond what could reasonably be documented as improvement. The therapist was concerned about the ethics of providing unwarranted and costly treatment to the patient. The owner, who was the primary source of referrals from the neighboring hospital, also demanded that the therapist acquire patients' signatures on insurance forms without disclosing that the physician owned the establishment. This, the therapist believed, compounded the physician's conflict of interest. He and several therapists employed at the hospital where the orthopedist had practice privileges requested that the hospital ethics committee consider this situation and the issue of physician referrals of patients to physician-owned services.

The immediate question facing the ethics committee was whether it ought to consider questions of business ethics and, if so, whether it could offer helpful suggestions concerning conflicts of interest. There were strong procedural and substantive obstacles to accepting this case for consideration.

The primary procedural question, how wide to cast the net of ethics committee deliberations, was complicated by the broad array of business ethics issues--from competition, advertising, and consumer protection to discrimination, downsizing, and takeover actions. When ethics committees are confronted with this vast range of managerial problems and recall that their initial mandate was to protect the doctor-patient relationship, they often decline to broach issues in business ethics. However, the sheer breadth of such issues does not preclude their consideration by ethics committees; it only warrants caution against precipitously taking on too many or too difficult business dilemmas. Moreover, even if we grant that ethics committees have a major responsibility to protect the doctor-patient relationship, the conflicts of interest raised by this case bear directly on that relationship. What is at stake is protecting the patient from unnecessary and expensive treatment proposed by a doctor.

Some committees claim that business ethics falls under the authority of another group, such as the board of trustees. No doubt decisions about certain issues, such as what services a hospital will provide, ultimately devolve upon the board. Even so, boards look to ethics committees for education about access to care and priorities in providing services. Although the board has ultimate authority to resolve ethical issues, this does not preclude ethics committees from addressing them.

The most serious procedural issue at stake is whether ethics committees would be coopted by institutional values if they considered business ethics cases. Committees that address cost containment efforts might be forced to support institutional values and the fiscal bottom line, not patients' values. We must ask whom or what ethics committees protect--the patient or the institution? This is something of a false dichotomy, for if these committees are protecting the patient they are as a matter of course protecting the institution. Still, obligations to protect the institution are not simply identical to those to protect the patient and ethics committees will always face a potential conflict between them. When they do, it is essential that they have clean hands and act conscientiously in the kinds of cases they accept or reject and the manner in which they evaluate cases.

The substantive issues that business ethics presents for a committee are no less troublesome. One way to avoid them altogether is to claim that health care should not be run as a business because the bottom line is at odds with the goal of benefiting patients. Some even suggest that business and the ethics of health care constitute an oxymoron--economics and ethics cannot overlap. Yet what is at issue is not making an either-or choice between them, but understanding how business can function ethically.

Business is inherently moral. Indeed, insofar as it is under voluntary control, all human activity has moral significance. Business is more than merely pragmatic, existing solely to make profits; it offers services and meets people's needs. More importantly, the very existence of a functional business depends on recognition of ethical principles. Business would be impossible if it did not accept such fundamental norms of ethics as promise keeping, truth telling, and treating others as you would want to be treated. If all business transactions were open to the notion that persons could be given inaccurate information to entice them to order unneeded goods or that recommendations to purchase goods or services could be based on the bias of parties who would gain unfairly, business would screech to a halt. The ethics of business require that consumers receive correct and reasonably unbiased information about goods or services. Ethics committees must recognize the patient's need to know and should be aware that virtually every major study indicates that physicians who make referrals to self-owned medical facilities recommend more expensive procedures than physicians without ownership interest. [1]

Finally, the substantive issues in business ethics create problems for ethics committees because business ethics is new and relatively unexplored. Ethics committees, having dealt solely with biomedical dilemmas, might be lulled into believing that only one ethical model exists to solve all ethical problems, including those that arise from business practices. This is not so. Different ethical models exist to explain different kinds of issues. Committees might find that, if anything, the moral method used in business ethics provides fresh avenues for wrestling with biomedical controversies.

Ethics committees will not be able to avoid considering business ethics, for the practice of business within health care will call for an evaluation of whether it is adversely affecting patient care. Given that business ethics remains at a relatively adolescent stage, perhaps it should be considered later in an ethics committee's development. At that time, committees could provide education on theories of business ethics, as well as guidelines for dealing with business dilemmas in health care. For example, a guideline requiring referring physicians at a hospital to present patients with the available referral options and inform them of any conflicts of interest could be discussed under the aegis of an ethics committee. To avoid whistle-blowing episodes, it would be useful to promulgate clear procedures for reporting error and abuse and to design appropriate protections for those who identify problems.

The question facing this ethics committee and all ethics committees is not whether business ethics should be considered at all, but how it should be considered.


[1] Mark Rodwin, "Physicians' Conflicts of Interest: The Limitations of Disclosure," New England Journal of Medicine 32 (1989): 405-408.

Philip Boyle is associate for ethical studies at The Hastings Center.
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Author:Boyle, Philip
Publication:The Hastings Center Report
Date:Sep 1, 1990
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