|
Home | Issues | eMJA shop | My account | Classifieds | Contact | More... | Topics | Search |
→ Previous article in this issue
→ Contents list for this issue
→ More articles on Administration and health services
→ More articles on Ethics
The Profession
Ethics, medicine and economics: integration in a hospital environment
Rapid and radical change in almost every facet of society has brought in its wake community anxiety, suspicion and hostility. Current examples in Australia include the impact of globalisation, the introduction of the goods and services tax, and the actions of the banks in phasing out local branches.
Even the health industry faces increased levels of public scrutiny and criticism. A recent example has been the aged-care institutions, charged with providing suboptimal facilities and services.1 Hospitals, too, both in the private and public sector, have received embarrassing media attention — the organ-harvesting scandal in the United Kingdom being but one example.2 Surprisingly, while such public pressure has resulted in many large companies formulating corporate codes of ethics, few hospitals, with the exception of some with religious affiliations, have adopted such codes. This may be due in part to many hospital staff having their own professional codes of ethical behaviour.
However, a hospital is more than the sum of its professional staff, and decision-making at a corporate level raises ethical issues. For example, ethical issues need to be taken into account in the allocation of scarce financial resources and the sometimes fierce interdepartmental battles for funding. The size of many hospital budgets brings them into the ambit of "big business" and, as such, boards must be sensitive to the bottom line of financial accountability. Currently, there is increasing pressure on all businesses, large and small, to establish their activities on a sustainable basis, incorporating "triple-bottom-line" accountability — decision-making must take into account not only financial outcomes but also human rights and the impact on the environment.3 Only when all these issues are addressed, it is argued, can legitimate and responsible decisions be made.
The question might be asked, why bother with a code of ethics when hospitals are governed by highly prescriptive laws and regulations covering just about every aspect of their activities — from occupational health and safety to environmental protection to paternity leave — and where the threat of litigation hangs heavily over the system? The simple answer is that, to maintain and develop a reputation with customers and the community and create credibility and trust in a "brand" or image, any organisation must these days go beyond pure legal compliance with regulations and avoidance of litigation. This requires a willingness to communicate the values under which the organisation will operate, and to be judged against those values. This is particularly important for community service organisations such as hospitals and even medical practices. In a code of ethics, a hospital is stating the values to which it is committed and which, in seeking to achieve its objectives, it will never violate. In short, the end never justifies the means.
Codes of conduct have been in use in the Australian medical world for many years (eg, the Central Sydney Area Health Service has had a code of conduct in operation since the early 1990s),4 and A statement of ethical principles for those who shape and give health care has been developed by the Tavistock Group (a group comprised mostly of UK and US healthcare professionals and ethicists).5 However, a recent initiative by the Austin and Repatriation Medical Centre (ARMC), a major metropolitan teaching hospital in Melbourne, is believed to be the first code of ethics adopted by a major non-religious public hospital in Australia.
Codes of ethics and codes of conduct are often assumed to be synonymous, whereas they perform quite different, but complementary, roles. To quote Lagan: 6,7
A code of ethics sits alongside a code of conduct and together they provide the ground rules for day-to-day behaviour as well as guiding how decisions might be made in unanticipated situations.
Typically a code of ethics spells out an organisation's values and principles; it both reflects and shapes the organisation's culture. It makes transparent the values framework by which management will manage the business and its employees and the core values that will underpin company policies. [On the other hand] a code of conduct is about what types of behaviour are acceptable in the workplace. It outlines the rules and measurements by which employees will be held accountable in observing the stated corporate values and principles.
Like all tertiary teaching hospitals engaged in research, ARMC conforms with the ethical requirements of the National Health and Medical Research Council. It also has a Patient Care Ethics Committee that deals with such issues as patient autonomy, and limitation-of-treatment policies. In 1995, a decision was made by the then Liberal State Government that the ARMC would be privatised. This naturally caused considerable concern. A major factor in this concern was whether the new "owners" of the hospital would adhere to the hospital's perceived high level of ethical concern and care for its patients. These ethical standards were nowhere codified. Therefore, a committee that included professional staff from the hospital — doctors, nurses and allied health professionals — together with community representatives set about developing a corporate code of ethics, to which some 200 staff members subsequently contributed. The plan was to present the code to the prospective purchasers of the hospital and seek their acceptance of it. In the event, the decision to privatise the ARMC was reversed, but the code had aroused so much interest that the ARMC Board decided to adopt it.
While staff contributions to the development of the ARMC Code of Ethics were substantial, its continued relevance depends on effective promulgation or it risks going the way of many similar well-meant projects. Firstly, the code must be displayed within the hospital in such a way that staff, patients and visitors are constantly reminded of its ethical standards. One American hospital, which has a code of ethics, has achieved this by placing framed copies of the code in critical positions, such as reception, outpatients, emergency and other departments. Secondly, staff intake programs must include a session on the importance of the code. Finally, publicity in the community is vital. Above all, a code of ethics must be a living document, and genuinely form the basis for the value system on which every person in the hospital operates, and is seen to operate — from the boardroom to the bedside to the boiler room.
The challenge to every incorporated body in the medical field, big or small, is to formulate a code of ethics that demonstrates its adherence to fundamental human values in the face of rapidly changing circumstances. Reconciling the ethics of responsible financial accountability and best-practice medical care has, in recent times, caused difficulties for hospital boards. Hence, the need for a code of ethics which covers both business and medical practice, and whose standards are higher than the minimum required by law. It is not an easy task and will become even more difficult in the future, but, in the long run, it will save hospitals and the practice of medicine many potential difficulties and enhance their status in the community. It is particularly important that such a code be regularly updated to reflect, among other things, emerging ethical issues in patient care and treatment in end-of-life situations and in the rapidly developing fields of life science, such as gene technology.
Corporate code of ethics
The Austin & Repatriation Medical Centre (ARMC) has adopted this Corporate Code of Ethics as an expression of its commitment to the community that it will apply the highest ethical standards to all its activities
Values
The Austin & Repatriation Medical Centre upholds the following values as being self evident and having both intrinsic worth and universal application:
The inherent dignity of each and every human being
The autonomy of the individual
The exercise of care and compassion
The practice of justice, fairness, honesty and integrity
The proper stewardship of resources
The advancement of knowledge and learning
The striving for excellence
Principles
These values will be guided by the following principles:
1. All individuals of whatever culture, class or belief will be treated with respect, including and especially those who are intellectually or physically impaired or disabled, incompetent or deceased.
2. All individuals, especially patients, have the right to make or be involved in decisions which affect their lives, and where applicable this right extends to include consultation with those who are close to the patients concerned.
3. The primary concern of the hospital will be the provision of compassionate care and treatment to its patients with every effort made to relieve suffering.
4. The principle of justice will be observed in the avoidance of all discriminatory practices and the provision of equal opportunity.
5. Organisational activity, including administration, will be conducted in a fair, open and collaborative manner.
6. Responsibility and accountability will be exercised in all decisions and actions at every level to ensure that the best use of resources is achieved.
7. The importance of research and teaching in every clinical discipline will be recognised and every effort made to ensure that all research is conducted at the highest scientific and ethical standards.
8. The hospital acknowledges that it shares both a natural and a cultural environment with a wider community and affirms its commitment to respect and nurture those environments.
9. The pursuit of excellence will be encouraged not only in clinical practice but in every field of activity with the aim of improving standards of service to the community.
Practices
In accordance with "best practice" policy of the hospital, the principles enunciated in this Corporate Code of Ethics will be implemented as follows.
Principle 1. Respect
The conduct of all staff will reflect a respect for the uniqueness of every individual regardless of disability, impairment or incompetence.
Such respect will be accorded to patients not only when they are living but also when they are deceased.
"End of life" decisions will be made with due regard to the patient's known wishes, the responses of the next of kin and the relevant hospital policies.
Principle 2. Autonomy
Patient participation in decisions relevant to their condition will be regarded as both important and valued. They will be provided with information relevant to their condition openly and honestly, encouraged to ask questions and, where clinically viable, given time to reflect and consult before responding.
Whenever possible, information will be made available both orally and in written form and in the patient's customary language.
Clinicians will explain clearly to patients the difference between procedures which are accepted practices and those which are related to research. In the latter case, ARMC research ethics policies will be strictly observed.
Principle 3. Compassion
Every effort will be made to relieve patients of unnecessary suffering as speedily and effectively as possible.
Special efforts will be made to identify and respond to unarticulated fears and anxieties.
Where possible the needs of next of kin and others closely related to the patient will be addressed with care and concern.
Principle 4. Justice
The hospital recognises that this principle applies to dealings with staff and "stakeholders" as well as with patients.
All patients will be afforded best possible treatment and care appropriate to their medical condition. There will be no discrimination based on race, culture, religion, sex or position in society.
Treatment will be determined according to need, likely benefit, and the responsible use of resources.
Legislation related to discrimination, harassment and equal opportunity will be observed both in the spirit and the letter of the law.
Grievance issues will be addressed speedily and fairly.
Principle 5. Collaboration
Mutuality of respect will be encouraged between those engaged in clinical treatment and patient care. The sharing of information and decision making will be practised in the best interest of the patients.
Unnecessary duplication of examinations, investigations and patient interviews will be avoided.
External agencies and individuals including ministers of religion who contribute to the patient's welfare will be afforded respect and assistance.
Before any innovative or experimental procedures are undertaken they will be discussed with other health professionals engaged in the patient's care.
Principle 6. Accountability
Clear guidelines of responsibility for the care of patients will be established.
Health care professionals will be encouraged to express concerns without fear of recrimination.
The allocation of human, financial and technical resources will be in accord with the hospital's policies and the responsible spending of public monies.
There will be a continuing review of resource allocation in the light of subsequent outcomes.
Principle 7. Research and teaching
All professions represented at the hospital will be encouraged to engage in high quality research both in clinical practice and academic study.
All research conducted within or under the auspices of the hospital will be subjected to scrutiny as to its scientific value and validity and according to the high ethical standards which the hospital holds.
As a teaching hospital it will endeavour to provide students of relevant disciplines with opportunities for clinical study at the highest standard.
The hospital will encourage and support the conduct of forums, seminars and other methods of education designed to assist staff and the wider community to a better understanding and practice of health related issues.
Principle 8. Environment
The hospital acknowledges that it shares a common natural environment with the surrounding community and will ensure that any potential threat to this environment emanating from the hospital will be speedily and effectively identified and addressed.
The hospital will support community initiatives for the preservation and enhancement of the natural environment.
Recognising the multicultural character of the social environment in which it operates, the hospital will encourage community involvement in its activities.
Principle 9. Excellence
The hospital will promote the pursuit of excellence at every level of its activities. Continuous quality improvement programs will be regarded as fundamental to this process.
The hospital will recognise and appropriately reward outstanding achievements on the part of individuals and departments.
The hospital will strive for world leadership in its clinical, research, teaching and administrative practices.
3 Mantaura Avenue, Taylors Lakes, VIC.
Max M J Griffiths, MBE, BA, BCom, BD, Chairman, Austin and Repatriation Medical Centre Human Research Ethics Committee.22 Baldwin Street, Gordon, NSW.
Ian T Dunlop, MA(Cantab), FAICD, FAIMM, Formerly, Chief Executive Officer of the Australian Institute of Company Directors.Correspondence: Mr Max M J Griffiths, 3 Mantaura Avenue, Taylors Lakes, VIC 3038. maxgriffithsATozemail.com.au
AntiSpam note: To avoid spam, authors' email addresses are written with AT in place of the usual symbol, and we have removed "mail to" links. Replace AT with the correct symbol to get a valid address.
|
Home | Issues | eMJA shop | My account | Classifieds | More... | Contact | Topics | Search |
©The Medical Journal of Australia 2002 www.mja.com.au PRINT ISSN: 0025-729X ONLINE ISSN: 1326-5377