Ethical Integrity in Health Care Organizations: Currents in Contemporary Bioethics

See Mantel J. , “The Myth of the Independent Physician: Implications for Health Law, Policy and Ethics,” Case Western Reserve Law Review 64, no. 2 (2013): 455–520.

See Schein E. , Organizational Culture and Leadership, 4th ed. (San Francisco: John Wiley & Sons, Inc., 2010): at 21.

Id., at Figure 2.1.

See Mantel , supra note 1.

See Eddy D. M. , “Variation in Physician Practice: The Role of Uncertainty,” Health Affairs 3, no. 2 (1984): 74–89.

See Schein , supra note 2, at 235–258.

See Mantel J. , “Spending Medicare's Dollars Wisely: Taking Aim at Hospitals' Cultures of Overtreatment,” Michigan Journal of Law Reform (forthcoming 2015).

See Kahan D. M. , “The Supreme Court 2010 Term: Forward: Neutral Principles, Motivated Cognition, and Some Problems for Constitutional Law,” Harvard Law Review 125, no. 1 (2011): 1–77. For example, studies have found that individuals have faster reaction times when generating and endorsing memories and beliefs consistent with conclusions that promote an individual's self-interest or desired ends. See Kunda Z. , “The Case for Motivated Reasoning,” Psychology Bulletin 108, no. 3 (1990): 480–498 (summarizing studies on biased memory search).

See Kahneman D. , Thinking Fast and Slow (New York: Farrar, Straus and Giroux, 2011): At 105; Regan M. C. Jr. , “Moral Institutions and Organizational Culture,” St. Louis University Law Journal 51, no. 4 (2007): 941–987. This does not mean deliberative reasoning cannot override our initial impressions – it can – but doing so requires mobilizing substantial mental focus, something individuals do infrequently, particularly when their mental capacity is otherwise taxed by the complexity of the situation or performing other tasks. See Kahneman , supra at 81; Moore D. Lowenstein G. , “Self-Interest, Automaticity, and the Psychology of Conflict of Interest,” Social Justice Research 17, no. 2 (2004): 189–202.

See Mantel , supra note 1; Grochowski E. C. , “Ethical Issues in Managed Care: Can the Traditional Physician-Patient Relationship Be Preserved in the Era of Managed Care or Should It Be Replaced by a Group Ethic,” University of Michigan Journal of Law Reform 32, no. 4 (1998–1999): 619–660.

Mano-Negrin R. Mittman B. , “Theorising [sic] the Social Within Physician Decision Making,” Journal of Management in Medicine 15, nos. 4–5 (2001): 259–266; Borbas C. , “The Role of Clinical Opinion Leaders in Guideline Implementation and Quality Improvement,” Chest 118, no. 2 (2000): At 24S–32S.

See Mantel , supra note 1.

See Wennberg J. E. , Tracking the Care of Patients with Severe Chronic Illness: The Dartmouth Atlas of Health Care , The Dartmouth Institute for Health Policy and Clinical Practice (2008): At 39, 46–49, 52 (describing the association between available resources and clinical decision-making). Although a possible explanation for the positive relationship between supply and utilization may be that regions with sicker patients acquire more medical resources because their patients require more care, researchers at the Dartmouth Atlas Project found that the prevalence and severity of illness accounts for remarkably little of the variation in utilization rates across hospital regions. Id., at 9.

See Baker L. , “The Relationship between Technology Availability and Health Care Spending,” Health Affairs Web W3–537, W3–542 (2003) (finding that greater availability of MRIs and CT units is associated with higher use and more spending). Cf. Brownlee S. , Over-treated (New Toek: Bloomsbury, 2007): At 161–63 (summarizing the comments of a hospital's chair of radiology, who stated that the availability of newer, faster machines “encourages physician to perform even more unnecessary tests,” thereby bolstering the hospital's revenue).

See Baker , supra note 14.

See generally Silverman H. J. , “Organizational Ethics in Healthcare Organizations: Proactively Managing the Ethical Climate to Ensure Organizational Integrity,” HEC Forum 12, no. 3 (2000): 202–215; Goodstein J. Lyman Potter R. , “Beyond Financial Incentives: Organizational Ethics and Organizational Integrity,” HEC. Forum 11, no. 4 (1999): 293–305; Renz D. O. Eddy W. B. , “Organizations, Ethics, and Health Care: Building an Ethics Infrastructure for a New Era,” Bioethics Forum 12, no. 2 (Summer 1996): 29–39.

See Zoubul C. , “Healthcare Institutional Ethics: Broader than Clinical Ethics,” in Health Care Ethics: Critical Issues for the 21st Century, Morris E. ed., (Sudbury, Massachusetts: Jones and Bartlett Publishers, 2009): At 237.

See id., at 237–239.

See id.

See Guinn D. , “Corporate Compliance and Integrity Programs: The Uneasy Alliance between Law and Ethics,” HEC Forum 12, no. 4 (2000): 292–302.

See Mantel , supra note 1 (discussing the competing obligations of HCOs).

See Mantel J. , “Accountable Care Organizations: Can We Have Our Cake and Eat It Too?” Seton Hall Law Review 42, no. 4 (2012): 1392–1442 (explaining the potential for accountable care organizations to achieve both lower costs and higher quality care).

Goodstein Potter , supra note 16, at 298.

Id., at 299.

See Silverman , supra note 16; Renz Eddy , supra note 16.

See Silverman , supra note 16; Renz Eddy , supra note 16.

Cf. Renz Eddy , supra note 16 (stating that building a new ethics infrastructure should be a “participatory process that involves those who have a stake in its operation”).

Hall M. A. , “A Corporate Ethic of ‘Care’ in Health Care,” Seattle Journal for Social Justice 3, no. 1 (2004): 417–428.

Cf. Renz Eddy , supra note 16 (comparing the narrow focus of hospital ethics committees to a broader ethics infrastructure).

See Goodstein Potter , supra note 16; Silverman , supra note 16.

See O'Toole B. , “St. Louis System Has Corporate Ethics Committee,” Health Progress 87, no. 2 (2006): 42–45.

Cf. Silverman , supra note 16 (urging that organizations have “forums that address ethics issues”); Goodstein Potter , supra note 16 (same).

See Pearson S. D. , No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence (New York: Oxford University Press, 2003): At 36–37.

See id.

Silverman , supra note 16, at 211.

Silverman , supra note 16.

Cf. Renz Eddy , supra note 16 (noting the importance of ethics and integrity audits that “assess whether the organization has lived up to its ethical standards”).

See Silverman , supra note 16.

See Foglia B. , “Preventive Ethics: Addressing Ethics Quality Gaps on a Systems Level,” The Joint Commission Journal on Quality and Patient Safety 38, no. 3 (2012): 103–111.

See id.

Although current Joint Commission standards for hospitals address hospitals' organizational culture, they focus on leadership creating “a culture of safety and quality,” ignoring that hospital leaders must balance these concerns with competing demands. See Joint Commission, 2015 Hospital Accreditation Standards (Illinois: Joint Commission Resources, Inc., 2015): At LD-16 to LD-20. The hospital accreditation standards also direct hospital leadership to address conflicts of interests involving licensed independent practitioners and/or staff that affects “the safety and quality of care, treatment, and services” in order to ensure ethical practices at the bedside and in the hospital's marketing and billing practices. See id., at LD.04.02.03. The Joint Commission's standards offer few guidelines for hospital leadership on the specific structures and processes hospitals should adopt in order to ensure their institution's ethical integrity.

For example, accountable care organizations could be required to adopt an ethics infrastructure as a condition of participation in the Medicare Shared Savings Program or analogous state Medicare shared savings programs, and hospitals and physician groups adopting an ethics infrastructure could be rewarded with higher payment rates under Medicare and Medicaid value-based purchasing initiatives.