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Ethics & Quality

NAHQ Annual Educational Conference

September 17-20, 2006

Jason E. Gillikin, CPHQ

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Agenda

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

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Introductory Comments

About your presenter About Spectrum Health State of the industry –

Moral philosophy Healthcare quality

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A Bit about Ethics

What “ethics” is NOT: Compliance Teamwork Psychology Social work Trendy “leadership” fad Manipulation tool

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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)

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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

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Initial Concepts

Metaethics What is the source of ethics? How do we know what is ethical? How rigidly do ethical rules/norms apply?

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Initial Concepts

Evaluation criteria for moral theories Consistency (usefulness) Determinacy (usefulness) Livability (usefulness) Publicity (usefulness) Coherence (correctness) External support (correctness)

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Initial Concepts

Absolutism (principles & processes) Agency Autonomy – does it matter? Determinism/free will Externalism (moral beliefs don’t

moviate moral actions) v. internalism

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Initial Concepts

Fact-value fallacy Heroism Instrumental value Moral facts; quasirealism Perfection of duty Projectivism

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Ten Major Systems

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

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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

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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

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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

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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

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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

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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

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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

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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”

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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

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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?

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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”

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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

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Strategies

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

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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

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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

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Resources

Blackburn, Simon. “Being Good.” Oxford, 2001

Ellin, Joseph. “Morality and the Meaning of Life.” Harcourt, 1995.

Furrow, Dwight. “Ethics: Key Concepts.” Continuum, 2005.

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Resources

Scruton, Roger. “Modern Philosophy.” Penguin, 1994.

Timmons, Mark. “Conduct & Character.” Wadsworth, 1999.

Veatch, Robert. “The Basics of Bioethics.” Prentice Hall, 2003.

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Conversation

Questions? Comments?

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