Social Responsibility: A New Paradigm of Hospital Governance?

Changes in modern societies originate the perception that ethical behaviour is essential in organization’s practices especially in the way they deal with aspects such as human rights. These issues are usually under the umbrella of the concept of social responsibility. Recently the Report of the International Bioethics Committee of UNESCO on Social Responsibility and Health has addressed this concept of social responsibility in the context of health care delivery suggesting a new paradigm in hospital governance. The objective of this paper is to address the issue of corporate social responsibility in health care, namely in the hospital setting, emphasising the special governance arrangements of such complex organisations and to evaluate if new models of hospital management (entrepreneurism) will need robust mechanisms of corporate governance to fulfil its social responsiveness. The scope of this responsible behaviour requires hospitals to fulfil its social and market objectives, in accordance to the law and general ethical standards. Social responsibility includes aspects like abstention of harm to the environment or the protection of the interests of all the stakeholders enrolled in the deliverance of health care. In conclusion, adequate corporate governance and corporate strategy are the gold standard of social responsibility. In a competitive market hospital governance will be optimised if the organization culture is reframed to meet stakeholders’ demands for unequivocal assurances on ethical behaviour. Health care organizations should abide to this new governance approach that is to create organisation value through performance, conformance and responsibility.     

The challenge of developing corporate citizenship for sustainable public health: An exploration of the issues,with reference to the experience of North West England

Choosing Health is the first English public health strategy to highlight the concepts of corporate social responsibility and corporate citizenship and discuss their importance for health improvement. Although the terms are used most widely in relation to private corporations, there has been growing discussion of their application to public sector organizations. The King's Fund report Claiming the Health Dividend led to a growing recognition that corporate citizenship within the National Health Service can make an important contribution to public health, regeneration, sustainable development and the reduction of inequalities—and a subsequent mapping exercise identified North West England as being one of the regions with a particularly well-developed approach. This paper introduces the concepts of corporate social responsibility and corporate citizenship; explores the theoretical and policy contexts relating to its application within the NHS—discussing links to sustainable development, Investment for Health and healthy settings; provides an overview of work within North West England with a particular focus on development work carried out with Salford Primary Care Trust (exploring how it could develop corporate citizenship work, specifically in relation to employment, procurement and transport); and critically reflects on and discusses emerging issues in the context of wider debates on global public health.     

Health Professionals: How much Employee Loyalty Should We Expect in a Privatising System?

In recent years UK government policy has been drawing private companies into the operation of the British National Health Service as providers of health care. Hitherto the National Health Service has been the main employer of health care practitioners, but this may change as a result of this development. There is an issue as to whether professional health care practitioners owe the same moral commitment to an employer in the private sector as they would owe to an employer that is part of the state-run National Health Service. I explore some arguments around this issue, focusing on ways of identifying organisational commitment to good health care. With regard to the practitioners commitment to the organisation I consider two strengths of commitment, normative and calculative. I then undertake an analysis of performance, regulatory regimes, and organisational obligations for both sectors. I conclude that while performance and regulatory regimes show little difference between sectors, there is a reasonably compelling argument in favour of a stronger moral commitment to state bodies based on organisational obligations.     

Restoring a reputation: invoking the UNESCO Universal Declaration on Bioethics and Human Rights to bear on pharmaceutical pricing

In public health, the issue of pharmaceutical pricing is a perennial problem. Recent high-profile examples, such as the September 2015 debacle involving Martin Shkreli and Turing Pharmaceuticals, are indicative of larger, systemic difficulties that plague the pharmaceutical industry in regards to drug pricing and the impact it yields on their reputation in the eyes of the public. For public health ethics, the issue of pharmaceutical pricing is rather crucial. Simply, individuals within a population require pharmaceuticals for disease prevention and management. In order to be effective, these pharmaceuticals must be accessibly priced. This analysis will explore the notion of corporate social responsibility in regards to pharmaceutical pricing with an aim of restoring a positive reputation upon the pharmaceutical industry in the public eye. The analysis will utilize the 2005 United Nations Educational, Scientific, and Cultural Organization’s Universal Declaration on Bioethics and Human Rights (UDBHR) to establish implications regarding the societal responsibilities of pharmaceutical companies in a global context. To accomplish this, Article 14 of the UDBHR—social responsibility and health—will be articulated in order to advocate a viewpoint of socially responsible capitalism in which pharmaceutical companies continue as profit-making ventures, yet establish moral concern for the welfare of all their stakeholders, including the healthcare consumer.     

Organizing emotions in health care

PURPOSE: To introduce the articles in this special issue, discussing emotion in the in health-care organisations. DESIGN/METHODOLOGY/APPROACH: Discusses such topics as what makes health care different, editorial perspectives, how health care has explored emotion so far, and the impact of emotion on patients and the consequences for staff. FINDINGS: Health care provides a setting that juxtaposes emotion and rationality, the individual and the body corporate, the formal and the deeply personal, the public and the private, all of which must be understood better if changes in expectations and delivery are to remain coherent. ORIGINALITY/VALUE: The papers indicate a shared international desire to understand meaning in emotion that is now spreading across organizational process and into all professional roles within health care.     

Why ethics should be part of health technology assessment

From the heydays of HTA in the 1970s, it has been argued that ethics should be a part of HTA. Despite more than 30 years with repeated intentions, only few HTA reports include ethical analysis, and there is little agreement on methods for integrating ethics. This poses the question of why it is so important to integrate ethics in HTA? The article analyzes ten arguments for making ethics part of HTA. The validity of the arguments depend on what we mean by "integrating," "ethics," and "HTA." Some of the counterarguments explain why it has taken so long to integrate ethics in HTA and why there are so many ethical approaches. Nevertheless, some of the arguments for making ethics part of HTA appear to be compelling. Health care is a moral endeavor, and the vast potential of technology poses complex moral challenges. A thorough assessment of technology would include reflection on these moral aspects. Ethics provides such a moral reflection. Health technology is a way to improve the life of human individuals. This involves questions of what "the good life" is, and hence ethical issues. Trying to ignore such questions may inflict with the moral foundation of health care: to help people. Additionally, HTA is an evaluation, and as such also a reflection on values. Hence, there is a profound affinity between HTA and ethics. Accordingly, ethics cannot be "integrated" in HTA as ethics is already a constitutive part of HTA. However, ethics can be acknowledged and emphasized.     

Institutional logic in self‐management support: coexistence and diversity

The prevalence of chronic conditions in Europe has been the subject of health‐political reforms that have increasingly targeted collaboration between public, private and voluntary organisations for the purpose of supporting self‐management of long‐term diseases. The international literature describes collaboration across sectors as challenging, which implies that their respective logics are conflicting or incompatible. In line with the European context, recent Norwegian health policy advocates inter‐sectorial partnerships. The aim of this policy is to create networks supporting better self‐management for people with chronic conditions. The purpose of our qualitative study was to map different understandings of self‐management support in private for‐profit, volunteer and public organisations. These organisations are seen as potential self‐management support networks for individuals with chronic conditions in Norway. From December 2012 to April 2013, we conducted 50 semi‐structured interviews with representatives from relevant health and well‐being organisations in different parts of Norway. According to the theoretical framework of institutional logic, representatives’ statements are embedded with organisational understandings. In the analysis, we systematically assessed the representatives’ different understandings of self‐management support. The institutional logic we identified revealed traits of organisational historical backgrounds, and transitions in understanding. We found that the merging of individualism and fellowship in contemporary health policy generates different types of logic in different organisational contexts. The private for‐profit organisations were concerned with the logic of a healthy appearance and mindset, whereas the private non‐profit organisations emphasised fellowship and moral responsibility. Finally, the public, illness‐oriented organisations tended to highlight individual conditions for illness management. Different types of logic may attract different users, and simultaneously, a diversity of logic types may challenge collaboration at the user's expense. Moral implications embed institutional logic implying a change towards individual responsibility for disease. Policy makers ought to consider complexities of logic in order to tailor the different needs of users.     

The Neglect of Racism as an Ethical Issue in Health Care

Race and racism has been increasingly implicated in known disparities in the health and health care of racial, ethnic and cultural minorities groups. Despite the obvious ethical implications of this observation, racism as an ethical issue per se has been relatively neglected in health care ethics discourse. In this paper consideration is given to addressing the following questions: What is it about racism and racial disparities in health and health care that these command our special moral scrutiny? Why has racism per se tended to be poorly addressed as an ethical issue in health care ethics discourse? And why, if at all, must racism be addressed as an ethical issue in addition to its positioning as a social, political, cultural and legal issue? It is suggested that unless racism is reframed and redressed as a pre-eminent ethical issue by health service providers, its otherwise preventable harmful consequences will remain difficult to identify, anticipate, prevent, manage, and remedy.     

The post‐2015 landscape: vested interests,corporate social responsibility and public health advocacy

This paper explores the tensions between UN calls for private sector engagement in the post‐2015 landscape and public health opposition to those ‘harm industries’ that are ‘corporate vectors of disease’ for the mounting global non‐communicable disease burden. The UN's support for public‐private partnership has provided industries with ‘vested interests’ in the propagation of unhealthy behaviours with new opportunities for the strategic alignment of their corporate social responsibility (CSR) endeavours with the post‐2015 sustainable development agenda. This has galvanised public health advocates to place pressure on the World Health Organisation to formalise their ambiguous stance towards private sector involvement in public policy formation and the resultant ‘conflicts of interest’. This paper critically examines the ‘gathering storm’ between this ‘anti‐corporate movement’ and the alcohol industry in the increasingly politicised domain of CSR. Drawing on the example of SABMiller's Tavern Intervention Program, the paper argues that CSR represents a profound threat to the sanctity and moral authority of the public health worldview. Questions therefore need to be asked about whether the public health‐led path of industry non‐association will necessarily result in health improvements or just a further retrenchment of the ideological faultlines explored in the paper.     

Living with conflicts-ethical dilemmas and moral distress in the health care system

During the last decade, the Swedish health care system has undergone fundamental changes. The changes have made health care more complex and ethics has increasingly become a required component of clinical practice. Considering this, it is not surprising that many health care professionals suffer from stress-related disorders. Stress due to ethical dilemmas is usually referred to as "moral distress". The present article derives from Andrew Jameton's development of the concept of moral distress and presents the results of a study that, using focus group method, identifies situations of ethical dilemmas and moral distress among health care providers of different categories. The study includes both hospital clinics and pharmacies. The results show that all categories of staff interviewed express experiences of moral distress; prior research has mostly focused on moral distress experienced by nurses. Second, it was made clear that moral distress does not occur only as a consequence of institutional constraints preventing the health care giver from acting on his/her moral considerations, which is the traditional definition of moral distress. There are situations when the staff members do follow their moral decisions, but in doing so they clash with, e.g. legal regulations. In these cases too, moral distress occurs. Hitherto research on moral distress has focused on the individual health care provider and her subjective moral convictions. Our results show that the study of moral distress must focus more on the context of the ethical dilemmas. Finally, the conclusion of the study is that the work organization must provide better support resources and structures to decrease moral distress. The results point to the need for further education in ethics and a forum for discussing ethically troubling situations experienced in the daily care practice for both hospital and pharmacy staff.     

Moral Distress and the Contemporary Plight of Health Professionals

Once a term used primarily by moral philosophers, "moral distress" is increasingly used by health professionals to name experiences of frustration and failure in fulfilling moral obligations inherent to their fiduciary relationship with the public. Although such challenges have always been present, as has discord regarding the right thing to do in particular situations, there is a radical change in the degree and intensity of moral distress being expressed. Has the plight of professionals in healthcare practice changed? "Plight" encompasses not only the act of pledging, but that of predicament and peril. The author claims that health professionals are increasingly put in peril by healthcare reform that undermines their efficacy and jeopardizes ethical engagement with those in their care. The re-engineering of healthcare to give precedence to corporate and commercial values and strategies of commodification, service rationing, streamlining, and measuring of "efficiency," is literally demoralizing health professionals. Healthcare practice needs to be grounded in a capacity for compassion and empathy, as is evident in standards of practice and codes of ethics, and in the understanding of what it means to be a professional. Such grounding allows for humane response to the availability of unprecedented advances in biotechnological treatments, for genuine dialogue and the raising of difficult, necessary ethical questions, and for the mutual support of health professionals themselves. If healthcare environments are not understood as moral communities but rather as simulated marketplaces, then health professionals' moral agency is diminished and their vulnerability to moral distress is exacerbated. Research in moral distress and relational ethics is used to support this claim.     

Third sector primary care for vulnerable populations.

This paper aims to describe and explain the development of third sector primary care organisations in New Zealand. The third sector is the non-government, non-profit sector. International literature suggests that this sector fulfils an important role in democratic societies with market-based economies, providing services otherwise neglected by the government and private for-profit sectors. Third sector organisations provided a range of social services throughout New Zealand's colonial history. However, it was not until the 1980s that third sector organisations providing comprehensive primary medical and related services started having a significant presence in New Zealand. In 1994 a range of union health centres, tribally based M?ori health providers, and community-based primary care providers established a formal network -- Health Care Aotearoa. While not representing all third sector primary care providers in New Zealand, Health Care Aotearoa was the best-developed example of a grouping of third sector primary care organisations. Member organisations served populations that were largely non-European and lived in deprived areas, and tended to adopt population approaches to funding and provision of services. The development of Health Care Aotearoa has been consistent with international experience of third sector involvement -- there were perceived "failures" in government policies for funding primary care and private sector responses to these policies, resulting in lack of universal funding and provision of primary care and continuing patient co-payments. The principal policy implication concerns the role of the third sector in providing primary care services for vulnerable populations as a partial alternative to universal funding and provision of primary care. Such an alternative may be convenient for proponents of reduced state involvement in funding and provision of health care, but may not be desirable from the point of view of equity and social cohesion insofar as the role of the welfare state is diminished.     

From corporate governance to hospital governance. Authority, transparency and accountability of Belgian non-profit hospitals' board and management

As a result of multiple developments in health care and health care policy, hospital administrators, policy makers and researchers are increasingly challenged to reflect on the meaning of good hospital governance and how they can implement it in the hospital organisations. The question arises whether and to what extent governance models that have been developed within the corporate world can be valuable for these reflections. Due to the unique societal position of hospitals--which involves a large diversity of stakeholders--the claim for autonomy of various highly professional groups and the lack of clear business objectives, principles of corporate governance cannot be translated into the hospital sector without specific adjustments. However, irrespective of these contextual differences, corporate governance can provide for a comprehensive 'frame of reference', to which the hospital sector will have to give its own interpretation. A multidisciplinary research unit of the university of Leuven has taken the initiative to develop a governance model for Belgian hospitals. As part of the preliminary research work a survey has been performed among 82 hospitals of the Flemish Community on their governance structure, the composition of the governance entities, the partition of competencies and the relationship between management and medical staff.     

The use of routinely collected patient data for research: a critical review

Over recent years in the UK there has been growing interest in the potential for routinely collected NHS (National Health Service) patient data to be used for secondary purposes, facilitated by the potential of increasingly sophisticated electronic databases. This article is based on a critically reflective literature review which analyses the key debates pertaining to this issue. The work arose in the context of a programme of research concerning routine patient data use in neonatal care. The article includes analysis of commentary (opinion and ethical inquiry) as well as empirically derived claims. It aims to deconstruct the knowledge assumptions on which relevant research studies have been based or are proposed and it also incorporates ontological position and moral argument. Results are presented according to three predominant debates: the prevailing claim that all health research benefits civic society; the varieties of informed consent and choices open to patients regarding secondary uses of their data; and the 'rights and responsibilities' of patients when it comes to their data being used for research purposes. It examines the relevance of these themes specifically to the neonatal context and the implications for our own research, concluding that employing an alternative ethical model to the traditional professional one might be useful in order to provide a further perspective on the issue.     

Scepticism about the virtue ethics approach to nursing ethics

Nursing ethics centres on how nurses ought to respond to the moral situations that arise in their professional contexts. Nursing ethicists invoke normative approaches from moral philosophy. Specifically, it is increasingly common for nursing ethicists to apply virtue ethics to moral problems encountered by nurses. The point of this article is to argue for scepticism about this approach. First, the research question is motivated by showing that requirements on nurses such as to be kind, do not suffice to establish virtue ethics in nursing because normative rivals (such as utilitarians) can say as much; and the teleology distinctive of virtue ethics does not transpose to a professional context, such as nursing. Next, scepticism is argued for by responding to various attempts to secure a role for virtue ethics in nursing. The upshot is that virtue ethics is best left where it belongs – in personal moral life, not professional ethics – and nursing ethics is best done by taking other approaches.     

Triad's new market strategy: a threat to community hospitals

Faced with unprecedented financial pressures, many nonprofit hospitals today contemplate hooking up with large corporations and converting to for-profit status. In the deals that result, the talk is largely about stock value and the interests of investors. The larger public-interest question of how the conversion will affect the health of community members often receives short shift. Most recently, Triad, an HCA spin-off, has emerged as a major player in the market for faltering nonprofits, zeroing in on institutions all the way from Alaska to North Carolina, and this has advocates worried, because the company can be singularly insensitive to community health care needs. But Triad is also remarkably adept at winning public favor. In this States of Health, we'll look at the broader public policy questions raised by such corporate health ventures, questions that point to the need for stronger oversight and regulatory mechanisms to assure that the public interest is protected in our increasingly market-driven health system.     

Does Moral Case Deliberation Help Professionals in Care for the Homeless in Dealing with Their Dilemmas? A Mixed-Methods Responsive Study

Health care professionals often face moral dilemmas. Not dealing constructively with moral dilemmas can cause moral distress and can negatively affect the quality of care. Little research has been documented with methodologies meant to support professionals in care for the homeless in dealing with their dilemmas. Moral case deliberation (MCD) is a method for systematic reflection on moral dilemmas and is increasingly being used as ethics support for professionals in various health-care domains. This study deals with the question: What is the contribution of MCD in helping professionals in an institution for care for the homeless to deal with their moral dilemmas? A mixed-methods responsive evaluation design was used to answer the research question. Five teams of professionals from a Dutch care institution for the homeless participated in MCD three times. Professionals in care for the homeless value MCD positively. They report that MCD helped them to identify the moral dilemma/question, and that they learned from other people’s perspectives while reflecting and deliberating on the values at stake in the dilemma or moral question. They became aware of the moral dimension of moral dilemmas, of related norms and values, of other perspectives, and learned to formulate a moral standpoint. Some experienced the influence of MCD in the way they dealt with moral dilemmas in daily practice. Half of the professionals expect MCD will influence the way they deal with moral dilemmas in the future. Most of them were in favour of further implementation of MCD in their organization.     

Is the corporate transformation of hospitals creating a new hybrid health care space? A case study of the impact of co-location of public and private hospitals in Australia

A common feature of health reforms in western nations has been the transformation or (re)construction of health and health care as both a commodity and product. In the hospital sector, this transformation has become increasingly evident in the growth of for-profit involvement in service delivery. Investor-owned hospitals are now prominent providers of hospital care in Australia. This paper examines the changing nature of health care space through the changing portrayal and meaning of hospitals as represented by and encoded in the built environment. Public hospitals once occupied 'pride of place'. In contrast, up to the early 1980s, the private sector was seen as a cottage industry. However, increased levels of state subsidisation and government incentives and pro-market policies, combined with market-based opportunities for profit generation, have seen the emergence of large private hospital chains with a new corporate image to hospital care and the blurring of 'public' and 'private'. A significant factor in the reconstruction of hospital space in Australia has been the co-location of private and public hospitals. Co-location is a popular strategy proffered by State governments and one that has been quickly acted on by corporate providers. Using Mayne Health Ltd, Australia's largest for-profit hospital chain, and four specific case studies, this paper explores four variants of co-location. Each of these examples represent a different public and private hospital space. The growth of for-profit hospital chains signifies a new phase in the delivery of health care in Australia but also importantly the creation of a new hybridised 'health care' space. This space is neither private nor public but a reflection of the economic, political and social processes underlying this transformation.     

TEACHING ETHICS IN THE ERA OF AIDS

AIDS has focused attention on deficiencies in medical education and in particular the teaching of ethics in medicine. The relative impotence of doctors to treat HIV/AIDS has served to remind them and other health workers that the ethics of care and prevention is ultimately about power-sharing with people. A holistic approach to ethics in medicine requires proper attention to be given to developing both professional competence and interpersonal competencies . These need to be developed at the Micro (Clinical), Macho (Interprofessional), Meso (Service Management) and Macro (Health Policy) levels. Like medicine, ethics is a practical discipline, requiring knowledge of general principles and skills in problem-solving . Both need to be learned in actual clinical settings, in interprofessional team-work, applied management of health services, and through participation in the development of ethical health policy (albeit for the local health centre, clinic or hospital). In ethics, as with general medical education, AIDS has shown that there needs to be more scope for person-centred and experiential learning, to build the kind of competencies that enable young doctors to deal with sensitive issues around sexuality, substance abuse, death and bereavement (particularly affecting people of their own age group). Instead of reinforcing the tendency towards the privatization of ethics, medical schools should follow the example of some leading business corporations in conducting institutional ethical reviews of systems and procedures, in developing corporate ethical policies , which will nourish the development of ethical competence in all staff and place ethics teaching in the context of total quality management .