A New Paradigm for Ethics in Health Care

Myth or reality? Ethical behavior is determined solely by upbringing and background.

Myth, says the Veteran’s Administration (VA) in its Ethical Leadership Primer. The reality is that organizational systems and culture powerfully influence ethical practice.

The VA has good reason to care about ethics in its own organizational systems and culture. It is under close public scrutiny to do the right thing for America’s veterans. Though VA employees are deeply committed to that mission, the difficult decisions they face every day―in the operating room or business office―give rise, inevitably, to complex ethics issues.

Another myth: ethics is about following your conscience or gut instincts. The reality: ethics involves analytic reasoning and is informed by specific knowledge and skills.

In 2007, when the VA set out to ensure that ethical practice permeates its health care system and medical culture, it recognized that its leaders and employees needed education and support in handling ethics issues. Shortly thereafter, it called on EDC’s Division of Health and Human Development (HHD) for assistance in designing training programs that apply ethics knowledge and skills to common dilemmas in health care. Rebecca Stoeckle, Director of Health and Technology, became immediately involved in the project. “People who are trained in analyzing medical conditions don’t necessarily know how to analyze ethical concerns,” Stoeckle explains.

Earlier this year, Rosemary Sedgwick joined EDC as a curriculum/instructional design associate, working with Stoeckle on the VA ethics initiative. “I am amazed at the enormous organizational challenge the VA has taken on,” Sedgwick says. “How do you transform the systems and culture of the largest integrated health care system in the U.S.―on limited public resources?” The Veterans Health Administration (VHA) is composed of 152 medical centers and 1,400 outpatient clinics, and cares for 8.3 million patients as diverse as the country they have served.

The VA started by establishing the National Center for Ethics in Health Care (NCEHC), a team of medical professionals drawn mostly from the corridors of VHA hospitals. They also have experience with VA’s renowned quality improvement initiative, and have brought a quality perspective to the ethics challenge. The team is small, but NCEHC thinks big. The challenge, as stated in its materials, is “to disseminate a systems-focused model to promote ethical practices in health care―and a new way of thinking about ethics.” This new paradigm is called IntegratedEthics.

IntegratedEthics (IE) defines the concept of ethics quality as “the interplay of factors at three levels: decisions and actions, systems and processes, and environment and culture.” Addressing ethics quality at each level requires a different expertise, hence, a different training program for the VA employees in the field who have added IE to their already long list of responsibilities.

EDC has been involved in instructional design at all three levels. A training program for VA ethics consultants―the people who respond to ethical concerns raised in day-to-day decisions and actions―was conceived in 2008 and rolled out over the past few years.

The focus in 2011 has been on the development of a program for the IE field teams who address ethics issues in VHA systems and processes. Sedgwick says the collaboration with NCEHC staff has been close and rigorous. “We were working on the instructional framework while they were developing the conceptual framework. A lot of the time, it was a chicken and egg process.”

The program, called Preventive Ethics: Beyond the Basics, was piloted in Seattle in August. Sedgwick is now working on a revised version (“with more participant interaction and fun,” she says), for delivery next summer.

The new paradigm for ethics in health care is gaining recognition beyond VA, as NCEHC has hoped. This year, IntegratedEthics was named one of the Top 25 Programs in the Innovations in American Government competition conducted by the Ash Center for Democratic Governance and Innovation at Harvard’s Kennedy School.