Ethics & Quality

1. Ethics & Quality NAHQ Annual Educational Conference September 17-20, 2006 Jason E. Gillikin, CPHQ

2. Agenda • Introductory comments • A bit about ethics • Challenges for application • Basic principles of ethical theory • Strategies for linking ethics & quality • Open discussion

3. Introductory Comments • About your presenter • About Spectrum Health • State of the industry – • Moral philosophy • Healthcare quality

4. A Bit about Ethics • What “ethics” is NOT: • Compliance • Teamwork • Psychology • Social work • Trendy “leadership” fad • Manipulation tool

5. A Bit About Ethics • “Ethics” – moral philosophy – is a branch of value theory that addresses the methods by which value-laden decisions are made among several possible outcomes • Principles of conduct (process) versus principles of value (outcome)

6. Challenges for Application • State of academic moral philosophy • Low degree of public knowledge about the essentials of moral theory • Belief that anyone can speak with authority about ethical issues

7. Initial Concepts • Metaethics • What is the source of ethics? • How do we know what is ethical? • How rigidly do ethical rules/norms apply?

8. Initial Concepts • Evaluation criteria for moral theories • Consistency (usefulness) • Determinacy (usefulness) • Livability (usefulness) • Publicity (usefulness) • Coherence (correctness) • External support (correctness)

9. Initial Concepts • Absolutism (principles & processes) • Agency • Autonomy – does it matter? • Determinism/free will • Externalism (moral beliefs don’t moviate moral actions) v. internalism

10. Initial Concepts • Fact-value fallacy • Heroism • Instrumental value • Moral facts; quasirealism • Perfection of duty • Projectivism

11. Ten Major Systems • Egoism • “I have moral obligations only to myself.” • Varieties, e.g., superenlightened egoism • One of the few truly self-consistent theories

12. Ten Major Systems • Relativism • “All of morality depends on the local culture.” • Denies universal truths • Usually not considered a true theory, but rather an objection to theory – but, often considered to be sufficient in itself by the uninformed • As such, acts like egoism with a social aspect

13. Ten Major Systems • Teleology (consequentialism) • “The moral content of an action depends on its consequence.” • Varieties, e.g., utilitarianisms • Usually have a few set maxims (e.g., “minimize pain and maximize happiness”) as guiding principles

14. Ten Major Systems • Deontology (nonconsequentialism) • “Although consequences matter, some acts are right or wrong independent of the outcome.” • Varieties, e.g., duty-based and rule-based ethics • The concepts of duty, honor and obligation form strong aspects of deontological moral analysis

15. Ten Major Systems • Virtue Theories • “Being moral means being virtuous.” • Good character is essential and can be habituated into existence • In Aristotle’s view, virtues are the mean between vices (e.g., bravery is the virtuous mean between fearfulness and rashfulness) • Emphasis on character, not process/outcome

16. Ten Major Systems • Care Ethics • “Morality consists in fostering relationships among people, and in responding to the perceived needs of others.” • Foil to the justice-based perspectives of utilitarianism and Kantian duty ethics • Strongly represented in medicine, pastoral care and social work

17. Ten Major Systems • Natural Law • “Morality consists in honoring the purposes and systems effected by nature.” • Strong current in Catholic moral theology • Can, in some ways, admit to social Darwinism

18. Ten Major Systems • Divine Command • “God’s will determines what is subject to moral praise or blame.” • Permits a high degree of absolute thinking • Internally self-consistent

19. Ten Major Systems • Social Contract/Rights Theories • “Man as a social animal has obligations to the broader society that cannot be ignored.” • Often not considered its own theory but rather a subset of deontology or rule utilitarianism • Expands traditional rule/duty systems by making society as a whole a primary moral agent – communitarianism – with emphasis on “rights”

20. Ten Major Systems • “Null Theory” • “Ethics? Nonsense.” • Denial that ethics is possible or meaningful • Often rooted in technical philosophy (e.g., philosophy of language) • Interesting implications for the analysis of sociopathic behavior

21. Terri Schiavo: Case Study • Should hydration be withheld? • Each theoretical system will provide a different answer, and a different justification for that answer • Then … what’s the right answer?

22. Why Link Ethics & Quality? • Whether they know it or not, people tend to adopt value systems that are consistent with the basic moral theories • Leveraging the motivating power of an ethical paradigm can improve a “culture of quality”

23. Strategies • Include all levels of staff in the decision-making aspects of the quality program, since people’s ethical response shifts as they grow in involvement or familiarity

24. Strategies • Communication – official and especially unofficial – should include the core concerns of the major theories (e.g., process, outcomes, duty) as justification points

25. Strategies • HOWEVER, do not presume to tell staff what their moral imperatives are – the locus of ethical decision-making is the self, not a health-care system; lecturing breeds cynacism

26. Strategies • Respect that staff members will have a variety of perspectives that are worthy of toleration • Remember that advancing one particular theoretical approach may alienate some staff members and make resolving dilemmas harder

27. Resources • Blackburn, Simon. “Being Good.” Oxford, 2001 • Ellin, Joseph. “Morality and the Meaning of Life.” Harcourt, 1995. • Furrow, Dwight. “Ethics: Key Concepts.” Continuum, 2005.

28. Resources • Scruton, Roger. “Modern Philosophy.” Penguin, 1994. • Timmons, Mark. “Conduct & Character.” Wadsworth, 1999. • Veatch, Robert. “The Basics of Bioethics.” Prentice Hall, 2003.

29. Conversation • Questions? Comments?

30. Spectrum Health The Comfort of World-Class Care