Ethical Complexity or Ethical Chaos?

A Prescription for Integrating Applied Ethics

The picture opposite, a deserted street in Keet Seel, an ancient Anasazi village in northern Arizona, serves at once as both a lifeless and vivid reminder that the complexity of life demands a direct tie between ethics and policy for our communities to be sustainable and capable of further evolution. In "simpler" times, people holding shared purposes, values, and visions of a desired future populated communities like Keet Seel. Such villages provided hope, identity, and purpose for the members of their communities.

The Anasazi, who built and populated them, survived and thrived as a culture for over a millennia. They lived in a harsh, dramatically beautiful environment, only to leave the high desert plateau they had called home within a few generations of building such villages. Leaving relatively suddenly and over a very short period of time in the thirteenth century, they ultimately lost their separate identity as they merged with other tribes, leaving more questions than their ruined villages, pots, rock art, and middens can answer.

If we are to achieve "sustainability," and avoid the fate of the Anasazi, the first step must be to learn to think and dialogue systemically in terms of levels of consciousness, connectedness, and processes.

Applied Ethics and Social Responsibility

Effective managers know that organizational success comes from identifying required tasks, assigning tasks according to individual and group abilities, and combining their efforts to achieve shared purposes. Applied ethics and policy analysis, however, has responded to an increasingly complex world by developing sophisticated, but separate and narrow, approaches. Examples include, but are certainly not limited to, business ethics, government ethics, biomedical ethics, codes of professional ethics, environmental ethics, and cost-benefit analysis, to name but a few.

The worst division—so serious as to constitute a schism—is between social responsibility and organizational ethics as disciplines. Here it is common in organizations to make a wholly artificial distinction between organizational ethics, or even business ethics, and social responsibility. The severe schism between ethics, especially organizational ethics, and social responsibility, especially corporate social responsibility, demonstrates that applied ethics and policy specialists may have lost sight of what ethics and politics were traditionally trying to accomplish: a good life for good people over a lifetime in society with others.

Now that we have a better understanding of our connectedness with an evolving world and our being as evolving members of that world, systemic responsibility must be seen to be a part of effective ethics and policy. To learn to think and dialogue systemically, leaders, managers, academics, and opinion molders need a framework for thinking and dialogue that harmonizes these diverse approaches: a tool to raise and treat the ethics and policy issues they face daily.

An effective applied ethics and policy integration model would bring together what ethicists and practitioners have learned through study, reason, and experience into an integrated framework to stimulate thinking, dialogue, and communities of ethical inquiry and practice. With the integration of ethical and policy approaches, we may approach ethical complexity equipped to achieve shared purposes. Without integration, a toolbox of such narrow approaches results only in bounded ethical framing and ineffective ethical communication, choice, learning, leadership, and action: in sum, ethical chaos.

First, a Word about Purpose

Before we proceed further, let me make the radical claim that all ethics and policy principles and practices are derived from or can be explained by four concepts that lie at the root of applied ethics: shared purpose, informed choice, responsibility, and learning and growth. As a guiding principle, moreover, the first among these four equals is shared purpose. The challenge to applied ethics is to integrate ethics and policy theory and practice to be consistent with them.

Is it simplistic to base all applied ethics on just four concepts? I think not because these four concepts reflect the evolved commonalties found among our human natures and support the drives that spur us to action. Consider, for example, why almost everyone values honesty, or would urge that people be, more often than not, honest:

• Purpose and honesty. Purpose gives meaning to our visions of a desired life. If those we deal with are not honest with themselves and others, we can never be sure that our purposes are shared. If purposes are not shared, we will often find, over time, that we are working at cross-purposes and that our efforts have been for naught. Virtually any decision or action can be accurately guided by simply asking, if I do this, will I be contributing to achieving my/our purpose in being?
• Choice and honesty. Choice is the essential activity that defines us as human beings. If those we deal with have not been honest with themselves and others, we may be making choices based upon bad information, or worse, our choices may have been made for us through the dishonesty of others. One is unlikely to achieve one’s purpose where the stakeholders in achieving one’s vision are not fundamentally honest.
• Responsibility and honesty. Responsibility, in the sense used here, means to be chargeable with being the author, cause, or occasion of something. We have authority to the extent we are the authors of our own lives. If we are the authors of our own lives, we are the cause of them, and responsible for them. If those we deal with have not been honest with themselves and others, they will be unable to exercise their authority prudently, and we will be unable to fix responsibility for the actions and consequences that affect us. Where authority is not exercised prudently, and we are unable to fix responsibility, we find ourselves in that twilight world where we can count on neither individuals nor communities: where we lose that sense of authorship of our own lives that makes us fully human.
• Learning and growth and honesty. Learning and growth are how the world evolved, developing the complexity of life and living that permitted human evolution. If those we deal with have not been honest with themselves and others, they cannot have that sense of brutal reality that compels action when reality differs uncomfortably from their visions of a good life. Moreover, they cannot have a realistic sense of the possibilities of human action. Without such an honest grasp of reality, others cannot learn and grow at a pace that leads to the diversity and integration that permits balance and harmony in a complex, evolving world.

Effective managers know that success comes from assigning tasks according to individual and group abilities, and then combining those efforts to achieve a shared purpose. The same dynamic is necessary in applied ethics, but seems to have gone largely unrecognized. Ethicists analyzed the broad discipline of ethics to meet immediate needs. Now it is time to synthesize what ethicists and managers have learned from study and experience.

The complexity of organizational life demands a direct tie between ethics and policy and rejection of simple formulas or sets of universal values. However, applied ethics has responded by developing increasingly sophisticated, but separate, and narrow approaches: business ethics, government ethics, codes of professional ethics, and environmental ethics. Managers now need a model harmonizing these approaches: a tool to raise and treat the ethics issues they face daily.

With the integration of ethical approaches, the manager approaches ethical complexity equipped to achieve shared goals. Without integration, a toolbox of such narrow approaches results only in bounded ethical framing, ineffective ethical choice, impotent ethical leadership, and unethical actions: in sum, ethical chaos.

Ethics in Health Care

Applied ethics specialties may have lost sight of what traditional ethics was trying to accomplish: a good life for good people over a lifetime in society with others. Ethical integration is essential for all organizations.

Ethics and policy integration is essential for all organizations, but let us use health care—a basic human need—to flesh out a framework integrating applied ethics and social responsibility. is may be especially true for health care, where there is a prevailing frustration among health care providers: "Business and health care do not mix." But, where health care is provided and funded by business, and received by business employees (and their families) as a significant part of compensation, this proposition is untenable. It reflects an unintegrated approach to health care ethics.

Integrating Applied Ethics

The Applied Ethics & Policy Integration Model, opposite, opposite dEPICts the integration of applied ethics and policy. It portrays a comprehensive applied ethics and policy framework for systems thinking and dialogue. This framework is as composed of four overlapping, specialized circles of ethical framing, choosing, communicating, choosing, and actingon, learning, and being all brought together by ethical leadership where they overlap at the sigma point ("S ").

Each circle represents an independent approach to applied ethics and policy: the ethics of Essential Social Responsibility, Social Purpose, Organizational Life, and the EnvironmentEcology. Within each circle are applied ethics and policy approaches raising and treating issues distinct to its own arena. A contribution from each circle is a necessary, but not sufficient, condition for an effective ethics system. Ethical leadershipp, at all levels, identifies those approaches that are appropriate to the context and culture of a particular organization or community and integrates them.

Ethics of Essential Social Responsibility

Within the Ethics of Essential Social Responsibility are three broad categories: government, for-profit, and not-for-profit. Each has broadly different responsibilities within society that , which are of the essence of its nature. Each has different stakeholderskey participants. Each has different constraints on action.

The essence of government is the appropriate application of its monopoly on the exercise of coercion and violence: the police, the military, and the courts. Its unique stakeholders participants are governors, the governed, and taxpayers. Bureaucracy and stability characterizes its institutions.

The essence of for-profits is meeting the most urgent needs of owners and consumers consumers of goods and services through free exchange: business and the professions. Its unique stakeholders are owners and consumers. Profits and adapting to changing customer needs characterize its institutions.

The essence of not-for-profits is meeting the needs and values of a community without coercion or exchange: charity or philanthropy. Its unique stakeholders are charitable organizations or associations (the independent sector or non-governmental organizations, NGOs), beneficiaries, and donors. Recognizing the needs of the defined community and soliciting community support characterize its institutions.

While the responsibilities of government and the not-for-profits seem relatively straightforward, it is helpful to think of social responsibility for business as occupying at least three distinct levels. The three levels of business social responsibility described in the box above reflect the essential characteristic of business as meeting the most urgent needs of consumers and the common characteristics of members of society, as described in earlier writings.

The essence of not-for-profits is meeting the needs and values of a community without coercion or exchange: charity or philanthropy. Its participants are charitable organizations or associations, beneficiaries, and donors. Recognizing needs of the community and soliciting community support characterize its institutions.

These are the essences, but there is much overlap, which makes ethical policy more difficult. In the area we are examining to develop this framework, of health care, for example, Ffederal subsidization of corporate employee benefits and Medicare and Medicaid are examples of the overlap of the sectors.

Ethics of Social Purpose

The Ethics of Social Purpose includes biomedical ethics, nursing ethics, banking ethics, legal ethics, accounting ethics, engineering ethics, marketing ethics, and or military ethics, to name but a few. Which bodies of ethics apply to a particular organization depends upon its purpose and vision—and the tasks required to achieve it.

Under some circumstances, such as a hospital in a combat zone, many of these ethics approaches would apply and need to be integrated. Doctors would look to their ethics; nurses, their ethics; judge advocates would apply the law of armed conflict, and their legal ethics; and all would be concerned with environmental ethics, including habitat destruction and medical waste disposal.

Ethics of Organizational Life

The Ethics of Organizational Life, or Organizational Ethics, is the domain of the ethics and compliance structures, systems, practices, procedures, and protocols necessary. Here, for a body of people having shared purposes employ organizational design and development to to achieve shared visions in accordance with the organization’s purpose, its core values, social responsibility, and core organizational culture.

Organizational ethics applies to all organizational life, regardless of specific social purpose. The thrust of organizational ethics is to increase human authority, energy, knowledge, and trust—, and to drive out fear. Organizational ethics applies to all organizational life, regardless of specific social purpose. It shapes the conditions of organizational life, the content of dialogue or conflict resolution, and the context for the ethical framing, communicating, choosing, learning, and actingons of the other circles. It is where ethical leadership may perhaps best be exercised, again at all levels.

Ethics of Ecological Relationships

The Ethics of Ecological Relationships, or, Environmental Ethics is the domain of the relationships between our species and the evolving world of which we are an integral part. It is the most fundamental of all approaches to applied ethics. It addresses who we are, , what we believe the rest the rest of the world of the world to be,is, and our relationship to it the world as as a whole.

In its most fundamental and comprehensive form, it is contains each individual’s worldview. Following the distinction between worldview and ideology made by the great Austrian Economist, Ludwig von Mises, between worldview and ideology, the other three circles represent ideologies, ways thought to be good or best to deal with the world as a whole. T But this circle of ecological relationship, however,, represents approaches to determining what is the best way to be an evolving member of an evolving approach the world of which we are an integral part. The other circless may be thought to have largely instrumental value. One’s relationship in the world is, by this definition, an intrinsic value.

Toward Integrated Health Care Ethics

Turning to patient care, there is clearly an ethical dynamic that goes far beyond biomedical ethics alone. But Howeveras, as the boxed quotation opposite suggestsshows, "the whole [of medicine] has often been likened to a jigsaw being pieced together by strangers, each of whom is only guessing at the picture." The Applied Ethics & Policy Integration Model is designed to help the manager bring these pieces together.

First, patient care depends in part upon the nature of the entity. Is this a governmental, for-profit, or not-for-profit hospital? Each area has different organizational providers, users, and payers. In concept, one area is politically driven, one is market-driven, one is community support-driven.

To what extent is the patient funding his or her own care? Since the cost of health care is largely financed by third parties (government, employer-paid insurers, or charity), this raises complex issues of individual and social responsibility, which any comprehensive ethics of health care must surface and treat.

Should the answers to these questions even be involved in determining the patient’s level of care? At first glance, the answer heard at the Emory course, a resounding no, seems right. But consider its implications. A governmental scheme typically provides something to which a limited part of a society is entitled at the expense of the rest, that is, the taxpayers. If government is single paypayer in a system, everyone is entitled at the expense of everyone else who pays taxes. This is inherently political, bureaucratic.

It can be no other way. Government patients have no real choice in the matter if they stay within the system. A veteran wishing to exercise his or her veteran’s benefits must go through a bureaucratic process. Welfare claimants deal with still more. Otherwise, the patient in a governmental scheme can demand all the care he or she desires—effectively having an unlimited right to tap the taxpayer. It is much the same for the not-for-profit hospital since only the method (but not the source) of fundraising is different. Only the for-profit hospital provides the patient with a direct choice of services; the patient can take his or her (insurance) money elsewhere.

Second, some speak of biomedical ethics, and the physician’s role in applying it, as though it were equivalent to health care ethics. But while biomedical ethics raises important health care issues, it is hardly comprehensive. Biomedical ethics, in its purest form, is only part of the social purpose of a health care system. Nursing, dealing more with care than cure, raises still other issues. Medical research and teaching raise still others. Biomedical ethics does not drive the health care system any more than engineering ethics drives uEPICn planning or the highway system.

Why? Because the essence of biomedical ethics leaves untreated significant ethical issues of individual and social responsibility, which impact all of us, health care providers in particular. At the 1997 Emory Intensive Course in Health Care Ethics, for example, a panel examined a hypothetical involving whether to provide lifelong health care to a 14-year old auto accident victim from various normative approaches: utilitarian, narrative, economic, and feminist. Not once was the concept of responsibility employed.

Consider the implications of such a view. A physician is to make a decision regarding the care of the patient without regard to the patient’s responsibility for his or her own condition or the resources available. He or she owes a patient unlimited advocacy for treatment without regard to past causes or future consequences; the physician "deals with the problem at hand."

In this view, Iit makes little difference that whether patients pursue a dangerous lifestyles (smoked, refused to wear a helmet, used IV drugs, drove while talking on a cell phone, etc.), choose to live life on the streets, and previously refused to follow medical advice. They are entitled to the same care as those who , or sacrificed sacrificed to maintain good bodily and mental health and to be sure he or she could afford quality health care. Further, under this view, it is not relevant that resources of time, energy, and money are limited across the health care system.

Certainly at the moment of care, the physician should have the primacy of the patient’s welfare in mind. That is a proper role of biomedical ethics. But reality requires that health care ethics take a broader view. Health care ethical framing and choosing must incorporate all appropriate approaches to ethics.

Rationing of care does exist. One need only look at waiting lists in government single-payer systems to see it in action. Moreover, w Where rationing does formally exists, the physician is generally precluded from advocating for the patient when there are no resources available within the system. Are physicians then acting unethically? Is the system unethical?

Surely neither the provider nor the system can can be deemed considered unethical, where since even the most liberal of health care policy proposals contain some limits. But if physicians in such systems, as well as the systems themselves, are deemed to be ethical under these circumstances, what meaning is to be found in a biomedical ethics of unlimited advocacy for the health care system as a whole? How can a system work when its principal decision-makers are charged only with "dealing with the problem at hand" and not with the system itself?

Thirdly, organizational ethics makes a difference. Ethical leadership is difficult. The bounds of responsibility for the care of a patient in a large hospital are often unclear, perhaps even, as Daniel F. Chambliss suggests, purposefully blurred. (See review of Beyond Caring on page 7.) Attending physicians make decisions bounded by the decisions and actions of interested others: administrator guidelines; day-to-day decisions by residents, nurses, and aides; and daily routines. Interdisciplinary fear characterizes much of hospital life: administrators vs. physicians, physicians vs. nurses, payers vs. providers, patients vs. the system as a whole.

Biomedical ethics ignores the systemic, organizational issues that Chambliss calls "ethical problems" as opposed to "ethical dilemmas." It ignores the difference between these and "ethical conditions," which cannot be changed, they just are and need to be dealt with, not solved. As a result, health care providers are left vulnerable to feelings of hypocrisy and fear when situations they deal with on a daily basis demand a broader view for resolution than biomedical ethics permits.

Taking such a narrow view results in physician decisions being constantly second-guessed by responsible others, who have different, equally limited, ethical and policy perspectives. It places physicians and nurses into situations where they feel hypocritical precisely because they do, in fact, make decisions based upon the limited time, energy, and, yes, money available.

Finally, the Ethics of Ecological Relationships must be considered. Health care takes place within a context of evolving life. We influence evolution in many ways, ours and other livesfe’s—and potential livefe’s. These ecological relationships define us. One way they define us is whether we are in harmony with our world, or at war with it. Whether we contribute to the world as a place for evolution, learning, and growth, or exploit it only as a means to maintaining existence. Even more at issue are the limits on action that we recognize on our capacity to influence the course of nature—and the evolution that naturally occurs within it. The fact that we have the authority to shape our lives, that is, the power to do something, does not mean that it should be done.

For example, to increase the quality of human life, is it appropriate, as a matter of policy, to destroy another species? Ee.g., the small pox virus?. Recognizing that some species evolve faster than we, and our technologies, evolve, is it ethical or even effective over the long run to kill members of a species to improve the quality of human life, ? Ee.g., antibiotic regimens?.

When is quarantine of the infected appropriate? When does human life begin? What are the long-term consequences of cloning life, especially human life? What is to be done with hazardous waste, especially bio-radiological and infectious waste? How far can the quality of other species’ lives be affected to improve the quality of human life? When does bringing a human being into the world or keeping a human being alive become inappropriate, unreasonably unnatural, or inhuman?

Training, Education and Development

At the S point, the point where all four circles overlap, lie the skills, knowledge, understanding and attitudes ("SKUA") necessary for shared purposes to be achieved, informed choices to be made, authority to be exercised, and learning and growth to occur. Together, the SKUA are essential for the necessary systemic thinking and dialogue to occur. The role of ethical leadership, then, is to bring together the required capacities and competencies through training, education, and development.

It is helpful to organize the S point SKUA into eight elements of ethics and policy integration:

• Caring: consciousness, awareness, commitment, and/or compassion
• Comprehensive thinking: critical, creative, and systemic thinking; choosing, judgment
• Communicating: dialogue involving feelings and ideas
• Cooperating: inquiry and action
• Exercising authority: leadership, followership, participation
• Knowledge: surfacing, capturing, sharing knowledge, including that which is tacit; knowing what you know, and what you don’t know
• Pride: self-esteem; stakeholder satisfaction and loyalty; and community sense of being
• Time: time preference, time frame, time available

Visualizing such a matrix, there is for each of the eight elements a package of training, education, and development to build and shape the SKUA required to be competent. Moreover, for ethics and policy to be integrated toward systemic thinking and dialogue and cooperative inquiry, action, and learning, these SKUA need to be developed at all levels of society: individual, family, organizational, community, nation, and global.

Implications for the Future of Health Care

We need serious, concerted efforts to integrate applied ethics and social responsibility at all levels, especially health care ethics at all levels. The An Applied Ethics & Policy Integration Model demonstrated here provides a foundation for the ethics and policy leader, academic, health care provider, and others. It allows them to to take a formal structural approach toward integrating biomedical, at least biomedical, nursing, and organizational ethics with its essential social responsibilities, and those of other key stakeholders in the health care system, including the environment..

An exciting part of the Emory Intensive Health Care Course was aOne structural approach in the health care arena is to integrate reported by Mary Ann Bowman Beil of Memorial Medical Center, Savannah, Georgia. Her hospital has established and integrated aorganizational corporate ethics, social purpose, environmental ethics, and social responsibility functions and function and a biomedical ethics committees. Committees of responsible people would be formed for each discipline and meet as often as appropriate. Representatives from each committee might meet monthly, integrate their perspectives, and present their views to the Chief Executive Officer, Chief Operations Officer, and Chief Medical Officer in a hospital, for example. This It is a great start toward dealsing with ethical complexity, by giving but essential social responsibility and accounting, marketing, engineering, and environmental and environmental ethics need formal voices as well as the more commonly heard voices of social purpose and, to a lesser degree, organizational ethics.

Conclusion

Hopes for building sustainable communities—socially, culturally, and physically—most be founded on learning to think and dialogue systemically. The Applied Ethics & Policy Integration Model provides a framework bringing together the remarkable work that has been done in ethics and policy toward that end. It is founded, in turn, on the four fundamental concepts of shared purpose, informed choice, responsibility, and learning and growth.

Again, using health care ethics as the example, Oon the theoretical level, we must put biomedical ethics into perspective and develop a truly comprehensive approach to health care ethics. Such an approach would take into account broader individual and social responsibilities. It would deal with the environmental aspects. It would address the toll the health care systems places on its practitioners. On the practical level, we need structures and systems integrating diverse ethical perspectives.

Taking both steps together, we will achieve the quality of care for patients, the quality of life for care givers, and the quality of dialogue on health care policy we need to avoid ethical chaos.

Though it is not a simple or quick process, In short, "Take two steps, and call me in the morning."

An earlier version of this article first appear in the newsletter: Ethical Management.