Business Ethics in Ethics Committees?
A physical therapist employed at a physician-owned therapy service became distressed when the owner, an orthopedic surgeon, required the therapist to continue care for a patient beyond what could reasonably be documented as improvement. The therapist was concerned about the ethics of providing unwarranted and costly treatment to the patient. The owner, who was the primary source of referrals from the neighboring hospital, also demanded that the therapist acquire patients' signatures on insurance forms without disclosing that the physician owned the establishment. This, the therapist believed, compounded the physician's conflict of interest. He and several therapists employed at the hospital where the orthopedist had practice privileges requested that the hospital ethics committee consider this situation and the issue of physician referrals of patients to physician-owned services.
The immediate question facing the ethics committee was whether it ought to consider questions of business ethics and, if so, whether it could offer helpful suggestions concerning conflicts of interest. There were strong procedural and substantive obstacles to accepting this case for consideration.
The primary procedural question, how wide to cast the net of ethics committee deliberations, was complicated by the broad array of business ethics issues--from competition, advertising, and consumer protection to discrimination, downsizing, and takeover actions. When ethics committees are confronted with this vast range of managerial problems and recall that their initial mandate was to protect the doctor-patient relationship, they often decline to broach issues in business ethics. However, the sheer breadth of such issues does not preclude their consideration by ethics committees; it only warrants caution against precipitously taking on too many or too difficult business dilemmas. Moreover, even if we grant that ethics committees have a major responsibility to protect the doctor-patient relationship, the conflicts of interest raised by this case bear directly on that relationship. What is at stake is protecting the patient from unnecessary and expensive treatment proposed by a doctor.
Some committees claim that business ethics falls under the authority of another group, such as the board of trustees. No doubt decisions about certain issues, such as what services a hospital will provide, ultimately devolve upon the board. Even so, boards look to ethics committees for education about access to care and priorities in providing services. Although the board has ultimate authority to resolve ethical issues, this does not preclude ethics committees from addressing them.
The most serious procedural issue at stake is whether ethics committees would be coopted by institutional values if they considered business ethics cases. Committees that address cost containment efforts might be forced to support institutional values and the fiscal bottom line, not patients' values. We must ask whom or what ethics committees protect--the patient or the institution? This is something of a false dichotomy, for if these committees are protecting the patient they are as a matter of course protecting the institution. Still, obligations to protect the institution are not simply identical to those to protect the patient and ethics committees will always face a potential conflict between them. When they do, it is essential that they have clean hands and act conscientiously in the kinds of cases they accept or reject and the manner in which they evaluate cases.
The substantive issues that business ethics presents for a committee are no less troublesome. …