July / August 2006
Recapture the Power of Ethics
It seems that ethics has been relegated to a back seat in our personal lives as well as in business, healthcare, government, and politics. It’s paid little more than lip service in our post-Enron, spin-doctored, market-driven culture.
To address some of our current problems, we need to take ethics seriously for a change. One forum in which to recapture the value and power of ethics is patient safety. Ethics can set the stage for how we decide what is right and wrong. It dictates a range of acceptable actions. Accordingly, we need to gain more comfort with using ethics as a problem-solving tool. Whether we are wrestling with difficult decisions in light of uncertainty or discomfort, weighing the elements of a complex dilemma, or developing guidance or policy, ethics merits and demands our best effort. In the patient safety domain, whether we are exploring the quality of communication from clinicians in honestly transmitting information to patients and their families when error and injury occur or addressing broader issues of policies and procedures, ethics can and should have a prominent role.
Ethics involves not only the content of what we do; it also involves the manner in which we do what we do. For example, in applying ethics to communication with patients, we know that it should be open, honest, complete, and transparent. It should attend to the literacy level of those with whom the discussion occurs. It must involve an appropriate apology when error occurs, particularly when that error results in an injury. These are fundamental issues of ethics: right action and professional propriety. Ethics mandates that we do the right thing for the right reason, do it right, and do it well. If indeed we want to “do things right,” we need the right tools. Those tools involve a process for identifying principles such as honesty, trust, integrity, fairness, consistency, accountability, and justice, which guide right action, as well as the ingredients and processes of decision-making.
We must also remember that ethics and knowledge are inextricably linked. A clue to that message can be found in the roots of the notion of informed consent, a concept that is central to communicating with patients. The etymological roots of consent, drawn from the Latin words con and sentire, capture the characteristic knowledge/ethics interface. Consentire, from which the English word “consent” is derived, is a combination of con, which means “together” or “with,” and sentire, which has two different meanings: “to know” and “to feel.” Consentire indicates that information must be transferred in a way that accounts for the knowing and the feeling of the particular person with whom we are attempting to communicate. Information must be communicated in such a way to insure that the patient “knows” what we are saying and understands and appreciates the significance of that information. Attention to both the cognitive and affective dimensions must occur. Patients put themselves in skilled hands because they have trust; clinicians have a duty to act in accordance with that trust. Part of that trust is telling them what they need to know to make a reasonably informed decision.
Ethics has value beyond enhanced communication and sensitivity to the personalized needs of the patient. Ethics as a discipline allows us to apply principles we value as we determine the best course of action, in essence “doing the right thing” in a wide variety of contexts and circumstances. There are different ways to determine the right thing and how we frame and clarify issues, weigh and test viable alternatives, solve problems, and justify our decisions. Whether we choose to be driven primarily by principles or choose to assess an array of alternatives, explore their practicality in light of counter examples, or “take the best from the best” by combining guiding principles and most viable alternatives is less important that the process and content of our decisions. Any of these approaches can be a healthy recipe for clarification, guidance, and resolution.
Ethics can help us explore the richness and robustness of how we interact with those we serve. We shortchange ourselves when we think of ethics as a casual afterthought rather than a more rigorous discipline. We need to rediscover and recapture ethics as a practical enterprise. In so doing we must remember that ethics is about right and wrong and how we justify our actions, not about “violations.” It’s not about infractions that lead to the convening of committees charged with ferreting out information and determining whether there was a legal violation. In this common exercise, compliance masquerades as ethics. Assuaging the OIG is not ethics!
Recapturing the heart and spirit of ethics requires moving from a minimalist view of ethics as an intellectual excursion or exculpatory exercise to something substantially more valuable and more expansive in application and scope. Ethics can help us embrace the most basic elements of what we do and how and why we do it and recapture the essence of who we are and what is demanded of us. As such, ethics becomes a driving force to help us become more rather than less, as well as to create architectures within which we and those we serve can more comfortably and reliably fit. A strong and firm ethical substrate can help us raise the bar and keep it high.
Dennis Robbins is a nationally prominent healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS). He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, and private industry, and government. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard. He is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare and member of several technical and scientific advisory boards. Robbins is also an adjunct professor at the W.P. Carey School of Business at Arizona State University, where he teaches graduate courses in ethics and health law. Robbins may be contacted at Dennis.Robbins@cox.net.