Foundations and essentials for the doctor of nursing practice

AMA Journal of Ethics, March 2020 183

AMA Journal of Ethics®
March 2020, Volume 22, Number 3: E183-186

FROM THE EDITOR
Organizational Ethics for US Health Care Today
Patrick S. Phelan

Since the foundations of medical ethics were laid in antiquity, the practice of
medicine has evolved in tandem with the landscape of health care systems.
Humanity’s wealth of contemporary clinical knowledge is accompanied by
profound complexity in our health care systems, where diverse types of
organizations (eg, hospitals, insurance companies, government agencies,
private health investment firms) play equally diverse roles in acquiring and
mobilizing resources. The significance of this complexity for health care ethics
has become a subject of increasing scholarly recognition and analysis. Indeed,
the integration of clinical and business ethics has produced an amalgam
known as “organizational ethics.”1

The interplay among hierarchy, management, and policy in current health care
systems suggests that an organizational ethics lens is indispensable for
appraising ethical problems.2 How should organizations maintain reasonable
expectations of professional employees? How should they promote ethical
conduct of their constituents? How should they foster public trust in science
and practice? The contributions to this issue of the AMA Journal of Ethics
address these and other timely concerns in modern health care systems and
illustrate ways in which ethical questions are often inextricably bound with
organizational constituents, cultures, and relationships.

A fundamental difference between organizational ethics and traditional health
care ethics is scope: traditional ethics focuses on individuals and
organizational ethics on collectives.3 Relevant collectives in health care—
including groups of clinicians, patients, nonclinical workers, administrators,
and institutions themselves—have diverse and often overlapping
memberships and interests that might conflict. Characterizing these
collectives is a challenge: corporate organizations can be effective
communities, and the aims of making profit and promoting public good can
stem from a common purpose.4

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Types of membership in health care collectives are multifarious; some groups
exist by virtue of a common profession or place of work, others are voluntary
associations providing a cohesive group identity (eg, labor unions). Where
union membership is an option for physicians in training, affiliation might
suggest to some physicians’ ethically relevant and possibly conflicting
interests and obligations, especially when collective action (eg, striking) is
considered.5

Where clinicians are employees, organizational culture can be understood as
expressing organizational values and establishing and enforcing
organizational norms. Moreover, organizations’ goals for ethical conduct can
be taken to reflect individuals’ particular ethical values.6 Organizations can
communicate and propagate these values through mission statements, and
such values can then be used to justify organizational goals or leveraged to
manipulate constituent attitudes.7 For better or worse, organizations can
establish employee responsibilities and norms of conduct as measures for
ensuring compliance.

Notions of transparency and trust surround relationships between health care
organizations and outsiders. Contributions to this issue also address when—
or whether—greater transparency begets greater trust8 and conflicts that
can arise between a health care organization and an individual member.9
Institutional transparency and conflicts of interest can affect patients and
constituents’ relationships—most importantly, those of clinicians and their
patients.10,11 Health care organizations’ interests and their potential conflict
with interests of others under their authority are of great ethical significance,
as partiality can threaten fiduciary obligations clinicians owe to patients.
Moreover, health care organizations’ interests can differ significantly from
those of entities external to health care (eg, private equity firms).12

Given uncertain futures for health care systems, we should expect
organizational considerations to be central in designing and delivering health
care services. We can look to this issue for guidance about ensuring
reasonable expectations of clinicians,13 responsibly navigating clinicians’
collective negotiations with employers,5 enabling justifiable adjudication of
disciplinary action against organization members,14 maintaining cultures that
discourage misconduct,15 sufficiently communicating and responsibly
leveraging organizations’ aims to promote shared decision making,7 crafting
solutions when there are few or no alternatives,9 and maintaining good public
relations to foster trust.8

AMA Journal of Ethics, March 2020 185

References
1. Ozar D, Berg J, Werhane PH, Emanuel L. Organizational Ethics in

Health Care: Toward a Model for Ethical Decision Making by Provider
Organizations. Chicago, IL: American Medical Association; 2000.

2. Potter RL. From clinical ethics to organizational ethics: the second
stage of the evolution of bioethics. Bioethics Forum. 1996;12(2):3-12.

3. Pellegrino ED. The ethics of collective judgments in medicine and
health care. J Med Philos. 1982;7(1):3-10.

4. McCrickerd J. Metaphors, models and organizational ethics in health
care. J Med Ethics. 2000;26(5):340-345.

5. Howard D. What should physicians consider prior to unionizing? AMA J
Ethics. 2020;22(3):E189-196.

6. Iltis AS. Organizational ethics and institutional integrity. HEC Forum.
2001;13(4):317-328.

7. Schueler KE, Stulberg DB. How should we judge whether and when
mission statements are ethically deployed? AMA J Ethics.
2020;22(3):E235-243.

8. Cain DM, Banker M. Do conflict of interest disclosures facilitate public
trust? AMA J Ethics. 2020;22(3):E228-234.

9. Kogan R, Kraschel KL, Haupt CE. Which legal approaches help limit
harms to patients from clinicians’ conscience-based refusals? AMA J
Ethics. 2020;22(3):205-212.

10. Levey NN. Medical professionalism and the future of public trust in
physicians. JAMA. 2015;313(18):1827-1828.

11. Cigarroa FG, Masters BS, Sharphorn D. Institutional conflicts of
interest and public trust. JAMA. 2018;320(22):2305-2306.

12. Casalino LP, Saiani R, Bhidya S, Khullar D, O’Donnell E. Private equity
acquisition of physician practices. Ann Intern Med. 2019;170(2):114-
115.

13. Gunderman R. How should commerce and calling be balanced? AMA J
Ethics. 2020;22(3):E183-188.

14. Tsan MF, Tsan GL. How should organizations respond to repeated
noncompliance by prominent researchers? AMA J Ethics.
2020;22(3):E197-204.

15. Drabiak K, Wolfson J. What should health care organizations do to
reduce billing fraud and abuse? AMA J Ethics. 2020;22(3):E217-227.

Patrick S. Phelan is a senior medical student at Washington University School
of Medicine in St Louis, Missouri. He completed the requirements for the
master of population health sciences (MPHS) degree in clinical epidemiology
and will be awarded the MD and MPHS degrees in 2020. Outside of clinical

www.amajournalofethics.org 186

medicine, Patrick’s academic interests include research methodology,
biostatistics, and ethics.

Citation
AMA J Ethics. 2020;22(3):E183-186.

DOI
10.1001/amajethics.2020.183.

Acknowledgements
I am grateful to Dr Jay R. Malone for his guidance and support.

Conflict of Interest Disclosure
The author(s) had no conflicts of interest to disclose.

The viewpoints expressed in this article are those of the author(s) and
do not necessarily reflect the views and policies of the AMA.

Copyright 2020 American Medical Association. All rights reserved.
ISSN 2376-6980