Tough Choices: Values-Based Decisions in Behavioral Health Care

Dominic Sisti, PhD Director, Scattergood Program for Applied Ethics of Behavioral Health Care Department of Medical Ethics & Health Policy University of Pennsylvania

Summary

1.  What are ‘values-based’ decisions? 2.  What are the methods by which we can make

values-based decisions? 3.  Is your organization equipped to make values-

based decisions? –  Structures –  Processes

Stipulations

•  Acting ethically is a good thing to do.

•  There are objectively better and worse decisions (i.e. ethics is not relative)

•  Organizational ethics is not merely legal compliance.

•  Organizations are moral agents.

Distinguishing Decisions: Amoral Choices •  Everyday preferential decisions – Shall I take 76 to work today or the back way? – Shall I have coffee or tea?

•  Minor trade-offs – Shall I allow my daughter to watch an hour of TV

while I prepare dinner? •  Major trade-offs – Shall I take a job in Nebraska for a promotion

and 40% raise or not?

Distinguishing Decisions: Ethical Choices Ethical decisions: Potentially effect others (or self) in important ways (i.e. harm, benefit) •  Micro-ethical decisions

–  Do I tell my wife I don’t like her dress or do I lie? –  Do I expense this lunch with a co-worker even if we could’ve had a

normal meeting?

•  Macro-ethical decisions –  Should the executive leadership team accept a bonus while also laying

off 25 employees to cut costs? –  Should we freeze raises while also building new state of the art

research facilities? –  Should we cancel health coverage and encourage employees to use the

exchange even if it means the business will incur a (less costly) penalty?

Values-based decisions

VBDs are those that challenge or test an organization’s ability to adhere to their stated mission.

The Mission A Mission Statement at the very least defines an organization’s reason for being. Foundational Questions •  How may an organization establish a mission? •  What is the source of an organization’s mission? •  What areas of concern should an organization’s mission

address?

Organizational integrity is the congruence of organizational action with its Mission Iltis, A. 2005. “Values Based Decision Making: Organizational Mission and Integrity.” HEC Forum 17(1).

Mission   Ac)ons  Organizational

Integrity

Examples of Organizational Ethics Structures Honor council – University of Virginia

Ethics & compliance programs – GSK

Health care ethics committees – Hospitals & long-term care facilities – Joint Commission

Organizational Ethics Structures: Higher Education

University of Virginia •  Community of Trust •  Criteria:

–  Act: was an act of lying, cheating, stealing committed?

–  Knowledge: did the student know, or should a reasonable University student have known that the act in question was lying, cheating or stealing?

–  Significance: Would open toleration of this act violate or erode the community of trust?

•  Entirely student run and governed •  Sophisticated judicial framework

and by-laws

Organizational Ethics Structures: Corporate •  Ethics & compliance

Programs – Ethics code and training – Ethics officers assigned

regionally – Ethics hotlines available – Consultation services

Organizational Ethics Structures: Health Care

•  Hospital ethics committees •  On-call clinical ethics consultants •  Joint Commission •  Key goals: education, consultation, policy

development

Holy Mercy Health System, a Catholic provider, has initiated discussions with Secularist-West Health System about a potential partnership that could eventually develop into a regional ACO. Both institutions see this partnership as critical to their business going forward. Holy Mercy Hospital forecasts it will not have the volume to sustain a profitable hospital business within ten years, though it is well-positioned in the long-term care and behavioral health sectors. In contrast, Secularist lacks long-term care and behavioral health care services. Therefore, by complementing interests, a partnership would serve both party’s long-term financial interests.

Holy Mercy is under the jurisdiction of the Ethical and Religious Directives for Catholic Health Care Services. Therefore, particular medical interventions are prohibited such as abortion, fertility services and contraception. In contrast, the mission of Secularist includes a statement that the system be committed to providing reproductive services.

Members of the community and medical staff at Secularist grow concerned that they will be unable to fulfill their mission in women’s health care. Members of the ethics committee at Holy Mercy are concerned that because the institutions would be financially connected they would be in cooperation with prohibited medical interventions.

Should they proceed with partnership negotiations or abandon the effort because their missions are seemingly in conflict? If they proceed how should they negotiate about “non-negotiables”?

Methods of Making VBDs

Legalistic – Compliance as ethics

Utility – Outcomes based – Add up all good consequences, subtract bad

Duty-based – Strict adherence to objective moral laws about

duties (i.e. truth telling)

Methods of Making VBDs

Pragmatic Ethics – Rooted in the philosophies of

Charles Pierce, William James and John Dewey

– Solution oriented dialogue, debate, openness to revision, empirically informed

– Non-idealistic; Realistic about stakes and imperfections

–  Virtue and wisdom based

Oversimplifying VBDs Ignoring  possible  outcomes  

Underes)ma)ng  risk  by  overemphasizing  benefits  of  new  policy  Pretending  public  or  stakeholders  won’t  find  out  about  the  decision  or  ra)onale  Discoun)ng  the  future;  overvaluing  short  term  costs  and  benefits  

Judging  risk   Denying  uncertainty  Pretending  that  world  is  ra)onal,  or  is  explainable  according  to  a  par)cular  rule  Expec)ng  perfect  evidence  Defining  or  framing  risk  in  nega)ve  terms  

Perceiving  causes   Blame  persons  rather  than  systemic  causes  or  organiza)onal  structures  Misunderstanding  omission:  Failing  to  take  ac)on  not  seen  as  causal      

Assump8ons  about  others  

Enthnocentrism  Stereotyping  In-­‐group  favori)sm      

Adapted  from  Boyle,  et  al.  2001.  Organiza(onal  Ethics  in  Health  Care.  San  Francisco:  Wiley.  

Is your organization equipped to manage VBDs?

An organizational ethics program consists of: 1. The right people: •  Ethics committee •  Ethics consultant •  Ethics officers

2. Clear processes: •  Consultation •  Independence •  Direct line to upper management

3. Adequate resources: •  Staff support •  Training •  Financial support

}  Culture  of    Ethical    Awareness