ON BIOETHICS AND BUSINESS ETHICS

Transcription

1 Revista Română de Bioetică, Vol. 13, Nr.1, January - March 2015 ON BIOETHICS AND BUSINESS ETHICS Silviya Aleksandrova-Yankulovska* Ronald Jeurissen** Abstract Traditional medical practice has changed enormously during the last decades and new responsibilities were imposed on physicians not only to care for patients but to be also health managers. This paper aims at comparing bioethics and business ethics, in their development and approaches to solving ethical dilemmas, with the idea that contemporary medical practice has been brought nearer to business and inevitably has encountered some problems typical for the world of business. Both fields developed rapidly in the second part of the 20th century but while bioethics developed from micro- to macro- business level, ethics moved from macro- to micro-level of ethical problems and reflection. Different philosophical theories are applicable to both fields, but the dominating one in bioethics is the principlism which is not popular in business ethics. Ethical issues in business are often identified by the results of certain business actions while in bioethics we rather reflect on problems per se. What seems to be the biggest challenge for bioethics and business ethics nowadays is the transgression of theory to practice - how to enable health professionals and businessmen to see the benefits of ethics in their real work. Certain methodological approaches are applicable to both fields. Beneficence to the patient is still the most important goal of medicine while client s satisfaction is one of many company s goals in a highly competitive environment. While we might still find ethical justification in decreasing quality of some products for the sake of company s survival, in medicine, endangering life and health of the patient on purpose can never be ethically justified. Keywords: bioethics, business ethics, principlism Corresponding author : Silviya Aleksandrova-Yankulovska - silviya_aleksandrova@hotmail.com *Medical University of Pleven, Pleve, Bulgaria **Nyenrode Business Universiteit, Breukelen, The Netherlands 25

2 Traditional medical practice has changed enormously during the last decades. It has been marked by technological advances, aging of world s population, increase in health needs and gradual insufficiency of resources. Health professionals have acquired new responsibilities towards patients and society. Nowadays they are expected to play a complex role not only as healers but also as health care managers. This paper aims at comparing bioethics and business ethics, in their development and approaches to solving ethical dilemmas, with the idea that contemporary medical practice has been brought nearer to business and inevitably has encountered some problems typical for the world of business. Without pretending of exhaustiveness, we rather aim at sharing our experience and raising discussion among bioethicists and business ethicists. The emergence Traditional medical ethics evolved rapidly into bioethics in 60s of the 20th century in the United States and about a decade later in Europe. Medical ethics as a system of moral rules, rules of etiquette and rules of professional behaviour used to refer to the deontology of medical profession. The enormous advances in biotechnology, biochemistry and pharmacology led to unbelievable changes in medical knowledge and practice. The new diagnostic and therapeutic interventions questioned the traditional goals of medicine (15). All that happened at the background of changing socio-cultural context, plurality of values, and emphasized personal autonomy. Physicians began experiencing difficulties to address all expectations of patients, relatives and society. Defining the notion of good was not so clear any longer. Traditional medical ethics could not provide sufficient guidance in that complex practice and needed to apply new approaches to moral decisionmaking as well as to start regarding interests of more parties. Models of philosophical analysis were employed in ethical reflection. Care teams were extended to include non-medical professionals like psychologist, social workers, ethicists and the patient s voice began to count in therapeutic decisions. At that background bioethics was born and broadly defined as systematic study of moral dimensions in life sciences and health care employing different ethical methodology in interdisciplinary context (13). About the same time business ethics emerged in North America as a result of numerous scandals and loss of confidence in corporations. The demand for corporate responsibility increased tremendously in the second half of the 20th century. On the other side, decisions that had to be made in business appeared to be more difficult and more responsible with their effects on corporative development and society as a whole. The individual values learned from family, religion, school or even experience could not provide the necessary guidelines for the complex business decisions. The new field of business ethics aimed at identification of ethical issues in the world of business, developing approaches for resolving them, providing ways of promotion of ethical behaviour within the organization and coping with conflicts between personal 26

3 Policy Doing good values and organizational values (5). The modus operandi In the search of methodology for justifying the moral conclusions bioethics tried to employ various philosophical theories. Being traditionally a normative field, however, medicine was not keen on abstract philosophical reflection. Thus the applied ethics, or the so called principlism, was welcomed as a theory in biomedical ethics. It belongs to the top-down (deductive) approaches of justifying moral judgments through applying principles to specific cases (2). The American ethicists Beauchamp and Childress published the first edition of Principles of Biomedical Ethics in It has been widely analyzed and criticized over the years and the authors gradually improved the next editions. Some preference for casuistry as more practical bottom-up (inductive) model of reasoning has been expressed. The reasoning of casuistry is based on comparison with similar case and repetition of the moral decision. Casuistry is especially appropriate in relation to the development of new field in bioethics clinical ethics. Business ethics also struggles with the question of what is good for business and tries to find the answer by applying different ethical theories. In business ethics the deductive method of applied ethics is not so widely supported compared to the bioethics. Much more attention is paid to virtue ethics, deontology and consequential theories (fig.1). Individual Processes Adaptability and responsiveness Principle Doing right VIRTUE ETHICS Virtue ethics Ethics of care ETHICAL LEARNING AND GROWTH Individual growth Communitarianism Ethical egoism DEONTOLOGICAL ETHICS TELEOLOGICAL ETHICS Kantian imperatives Discourse ethics Rights Utilitarianism Justice as fairness Institutional structure Fixity and consistency Fig. 1 Framework for ethical theories (modified from Fisher and Lovell) The ethical theories on the left side of the framework on fig. 1 determine what is right according to predetermined principles and standards. They take no regard of the consequences of an action. The 27

4 theories on the right side of the framework measure the rightness according to whether the thing under question brings us closer to the desired state. Regarding the vertical dimension, the theories on the top emphasize individuals responsibility to develop themselves by acquiring judgment and self-knowledge. The theories in the lower half of the framework are concerned to develop fixed structures, institutions, that are independent of us but which determine principles and govern ethical deliberations (6). Some authors, however, see the theories as incomplete, oblivious to the concrete business context and indifferent to the very particular roles that people play in business (14). At any case, if we assume that there are principles involved in business ethics, they differ from the principles of Beauchamp and Childress that are cornerstone of biomedical ethics. The content of the applied ethics in business is different from the applied ethics in medicine. The latter is more or less equalized to principlism. The popularity of principlism in biomedical ethics can be explained by the individual focus of bioethics. Its emergence was triggered by the appeal to respect patients autonomy that was brought in medicine as a repercussion of social rights movements. Bioethics has been concentrated on individual good and just recently has developed interest in public health matters. In that way bioethics has moved from micro- to macro-level and has even incorporated macro-level considerations in decisionmaking process on micro-level. In business we can also distinguish three levels on which ethical problems can arise: micro-level of individual human action, meso-level of company s activity and macro-level of economic systems (9, 12). It seems that the focus of business ethics is mainly on meso- and macro-level issues, or at least, these issues have triggered the development of business ethics. The growth of the field has brought the individual ethical issues at the foreground. We can say that business ethics moved from macro- to microlevel of ethical problems and reflection. And still these individual considerations in business ethics are quite differently shaped in comparison to bioethics. The decisions that individuals face in the business world are more bound to the compliance with company s values, the achievement of company s goals, saving company s image and not that much centred on what is good for the decision-maker himself. In medicine, on the contrary, decisions are patient-centred. Just recently the family-centred approach has been proclaimed in different situations, mainly in cases of nonautonomous patient and surrogate decision-making (4,8,11). Even in these situations, though, ethical reflection is dominated by principlism aiming at balancing respect for autonomy, beneficence and nonmaleficence. On the other side, health care professionals are part of an institution and broadly speaking, part of a profession. They are responsible to keep the image of the profession but still their first and utmost priority is to do good for the patient. Bearing all this in mind, we can understand why principlism, which is more individually tailored theory, is so popular in bioethics. There is also another interesting difference that is worth to be pointed 28

5 out. Ethical issues in business are often identified by the results of certain business actions. These results might appear and draw attention over the time (7). Reflecting on the action that brought the problem we actually apply retrospective analysis. On the basis of this retrospective analysis we often try to elaborate guideline for conduct in similar future situations (16). In biomedical ethics we rather reflect on problems per se, sometimes long before they become real issues. We can trace this approach back to the philosophical traditions in ethics and it also presents the pursuit of ethical problems prevention. If we look at the hot contemporary debates in bioethics, they are all focused on the borderline of moral acceptability of technological advancement. We had been terrified, for example, of the effects of geneticization long before it became a real danger. The approach to ethical case analysis It is difficult, not to say impossible, to depict only one specific approach to ethical case analysis in the fields of bioethics and business ethics. There are many schools of thought in both areas and many suggestions to ethical decision making process. Hereby, we would like to present two approaches applied by ourselves in our teaching practice with students in medical ethics and business ethics courses. Approach to ethical case analysis applied in bioethics courses in Medical University of Pleven, Bulgaria 1. Determination of the moral problem(s). The problem should be determined impartially. The students must not take any side at that point. The problem can be formulated as a simple question, conflict between principles or definition of the area of ethics under question. The definition of the moral problem should be done from the position of the physician (or other health professional involved in the case) since the analysis aims at providing feasible advice for action to the practitioner. Thus the definition should clearly point to the immediate problem in front of the physician. 2. Description of relevant facts: Medical dimension. All medical data, available in the case, should be derived. Additional relevant information can be provided but only those data that could through light on the moral problem. Students are supposed to look for information from different sources (if they get case analysis as home assignment) or to ask open-ended questions (if the analysis is done in the class room) to show their awareness of the necessity to clarify certain facts. Patient s values. What values of the patient are at stake in the case? Organizational dimension. Detailed information should be provided about international and national ethical documents concerning the moral problem, legal 29

6 regulation and existing practical guidelines. 3. Ethical discussion (application of ethical theories). Students are required to apply principlism to the case. Each principle should be applied separately. The students should provide clear interpretation of the principle and should relate it to the moral problem. Thus they suggest some preliminary ethical decision based on the applied principle. Students are advised to start with the principle of respect for autonomy in the view of different ways of dealing with competent and incompetent patients. The questions that are usually asked in this stage of the analysis are: Is the patient in the case autonomous? If No, who should take decisions instead of him? If Yes, what means to respect the autonomy of the patient in this specific case? The interpretation of principle of beneficence presents a big challenge to the students. They have to open their minds to different ideas of good for the patient medical good, religious good, social good etc. Each idea of good for the patient should be related with a suggestion for ethical decision of the moral problem. Principle of non-maleficence can be discussed separately or in combination with beneficence. Principle of justice is one of the most difficult for interpretation. For practical reasons it is reduced to equal treatment (non-discrimination) of patients. As for the unequal distribution as part of the idea of distributive justice, students reflect on the application of different theories to resource allocation cases in health care. In conclusion of part 3 of the analysis, students summarise the conflict of principles they have encountered and they are stimulated to apply other theories to the moral problem. 4. Ethical Decision. The ethical decision should be given as an advice or recommendation to the colleague involved in the case. It should be concrete, feasible and consistent with the discussion (1). 30

7 Intervision model of six steps for ethical-decision making applied in business ethics courses in Nyenrode Business University 1.What is the core problem of the dilemma? Formulate the core problem as follows: should I do/refrain from doing XYZ? Test: Accuracy of the definition of the core problem. 2.Who are stakeholders in the dilemma? Which people or parties involved should I take into account in my decision? Whose rights, interests or well-being count in my decision? List the interests or values they represent! Test: Completeness of the inventory and accuracy of the assessment of the interests. 3. What relevant rules or guidelines apply to the dilemma? List the relevant rules, regulations and guidelines that are relevant to the dilemma. Sources of these rules, regulations and guidelines can be law books, covenants, the Code of Conduct or other published sources. Also list the core responsibilities of your company, team and function Test: Completeness of the inventory and accuracy of the interpretation to the dilemma. 4.What arguments can be brought forward? To formulate a reasoned position with respect to the core problem of the dilemma, it is necessary to make an inventory of all the relevant arguments that can be formulated. Arguments in defense of my considered action and arguments against my considered action. The objective of this inventory is not to neutralize opposing arguments, but to make sure, and to show, I have taken all relevant arguments into account. Make sure all stakeholders, rules, regulations, guidelines and all relevant values have been taken into account (check with steps 2 and 3). In my conclusion I can try to minimize the damage made. Categorize the arguments according to deontological (principled) or consequentialist reasoning. Test: completeness in the inventory and accuracy of the assignment of weights to the arguments. 5.What is my conclusion? When all arguments pro and con are listed and given their proper weight, a final conclusion can be formulated. In this conclusion the responsible decision can be 31

8 supported by solid arguments and by having taken into account all relevant stakeholders. Test: Consistency of the conclusion as compared to the weighing of the arguments. 6.Will I do it? Do I support this conclusion? Can I still face myself, and others? Am I actually going to act according to my conclusion? Can I account for my conclusion amongst my colleagues and stakeholders? (10). Test: Credibility compared to one s own intuitions and practical feasibility Comparing the two approaches we can point out several differences: In the 6-steps model, the formulation of the moral problem is in first person. In bioethics, the formulation of the moral problem is more often made in third person. It is done with the view of the prospective role of an ethics consultant and the increasing development of clinical ethics consultation services. Furthermore, in bioethics the interests of the patient come first. The interests of other parties are taken into account in the interpretation of principle of beneficence. However, if we conclude about an existing conflict between patient s interests and interests of other parties, we have two options. We can either encourage the communication between the parties in view of reaching consensus or we can directly undertake the course of action that is in the best interest of the patient. In business ethics different stakeholders may have strongly different interests, so the need for consensus is much less perceived than in medicine. Clarification of medical data is of crucial importance for bioethical case analysis. The lack of understanding over the medical dimensions of a case often results in poor ethical analysis. In business ethics details of the situation are also important but they rarely require special knowledge to be understood. The organizational dimension, consisting of ethical norms, laws and guidelines, is stressed in both approaches for ethical analysis. It is of significant importance in order to reach feasible final decision. The biggest difference between the bioethical approach and the business ethical approach to case analysis we see in the ethical discussion process in itself. The 6- steps approach gives preference to the development of arguments for and against certain action. It seems that in this model we approach the case with one or more ideas of solution and we investigate the arguments around these possible ways of action. The bioethical model, on the contrary, is more like approaching the case with blank page mind and digging up the alternative solutions. It is mainly based 32

9 on the classical principlism of Beauchamp and Childress (3). The everlasting popularity of this theory in bioethics can be attributed to its rather mathematical approach to ethical dilemmas. In comparison, deontology and different types of consequentialist reasoning seems to be more suitable for business ethics. The 6-steps approach suggests an interesting last step of selfrevision. In bioethics we usually don t have such step. It appears to be unnecessary as long as the ethical decision is formulated in third person. Once we give our advice to the physician, it s up to him/her to decide whether he/she will follow it or not. However, some bioethical schools of thought suggest last step of formulating directives for analogous cases. The specific goal of this last part is to draw indications which might become helpful in dealing with other similar cases. The need for such indications is derived from the sense of urgency in which clinical decisions must be taken. In such situations it is important to count upon a guiding orientation (17). Additionally, ethics committees might have the specific task to develop practical guidelines for common ethical problems in clinical practice. The model of ethical analysis then will be applied in accordance to this specific task and in order to provide sound argumentation to defend the elaborated guidelines. Thus, in some bioethical cases we have a level of proceduralization of ethical decision-making that is not applied in business ethics, because ethical problems in business pop up much more ad hoc and at random, and they are much more difficult to categorize, partly because their numbers are too small (table 1). Table. 1 Main points of comparison between bioethics and business ethics Bioethics Business ethics Dominant theories Principlism Deontology Consequentialism Focus Individual Organization Development From individual to society From macro- to micro-level Reflection on Problems per se Results from business actions Consensus Desirable Not necessary Specific knowledge Necessary In most cases not necessary Case analysis approach Applying principles to Starting with several ideas of solutions and looking for 33

10 suggest solutions arguments for and against Self-revision in the end Not typical Yes Type of cases Allow proceduralization Variety The obstacles Both fields medicine and business are used to work with concrete numbers, values, and norms. Businessmen and health professionals are used to work on the background of insecurity and probabilities of success but they are not in favour of philosophical approaches. On the other hand, ethics doesn t provide the right answers but rather encourages the development of own moral decisionmaking process. Ethical theories provide means of legitimating the stances you take on an issue rather than sources of definitive or authoritative solutions (6). Both fields medicine and business recognized the need of ethics almost at the same time and introduced ethics education in the curricula. What seems to be the biggest challenge for bioethics and business ethics nowadays is the transgression of theory to practice. We have brilliant scholars and teachers in both bioethics and business ethics. There has been released enormous amount of publications on bioethics and business ethics over the time. But we still face difficulties to explain to the public (and ourselves) what bioethics and business ethics on first place is. And we still struggle with the question how to enable health professionals and businessmen to see benefits of ethics in their real work. Merging fields Nowadays medical practice is soaked up with business relations and necessity of taking business decisions. It has even become a practice for some hospitals to hire managers from other fields in order to provide better clientoriented care. However, health care managers need to know something about clinical ethics, simply because these issues are important in the organizations in which they work. But knowledge of clinical ethics is not enough. Understanding the nature and limits of a patient s right to refuse treatment will not provide much help in determining just wages for nursing staff for example. Understanding the requirements for informed consent in therapeutic research does not clarify the nature of responsible advertising (18). So some knowledge of business ethics will certainly be of benefit for the health care management. Vice versa understanding of medical dimensions is significant for business decisions in health care. After all, can we claim that there is only one ethics applicable to all fields? Conclusive remarks Both Medicine and business developed rapidly in the 20th century and almost at the same time both felt the need to change. Bioethics and business ethics emerged as a result of this striving for a change. What change of values brought that development? Are we getting better looking for ethics 34

11 or we have become so bad that the need of ethics is inevitable? What is there at stake in business and medicine nowadays? Is it only about increased autonomy of patients and people as a whole or the trust has decreased simultaneously? If we make a step back to the beginning of our discussion, corporations made some dirty deals that led to scandals and loss of trust. What had medicine done to lose patients trust? May it be the case that medicine, struggling with increased demands and costs of health care, has become too much of a business? If so, can we borrow approaches from business ethics to solve current ethical problems in health care? Are there specific business ethics approaches or ethics is all the same and applicable to all fields? These and probably many other questions can be raised when questioning the demarcations between bioethics and business ethics. Although they have different focus, certain methodological approaches apply to both fields. Beneficence and patient care are still the most important goals of medicine while client s satisfaction is one of many company s goals in a highly competitive environment. While we might still find ethical justification in decreasing quality of some products for the sake of providing staff wages or survival of the company, in medicine, endangering life and health of the patient on purpose can never be ethically justified. References [1]. Aleksandrova-Yankulovska, S. (2014). Method For Ethical Case Analysis Applied In The Medical University Of Pleven. In: S. Aleksandrova-Yankulovska & H. Ten Have (eds.), Ethical Decision-Making in Health Care, (pp.7-9). Publishing Center of Medical University of Pleven. [2]. Beauchamp, T.L. and Childress, J.F. (2013). Principles of Biomedical Ethics. Oxford University Press, pp [3]. Beauchamp, T.L. and Childress, J.F. (1983). Principles of Biomedical Ethics. Oxford University Press. [4]. Billings, J.A. (2011). Part II: Family-Centered Decision-Making. Journal of Palliative Medicine, 14(9), [5]. Ferrel, O.C., Fraedrich, J., Ferrel, L. (2013). Business Ethics. Ethical Decision-Making and Cases. South Western, Cengage Learning. [6]. Fisher, C., Lovell, A. (2009). Business Ethics and Values. Individual, Corporate and International Perspectives. Pearson Education Limited. [7]. Fraedrich J., Ferrell, O.C., Ferrell, L. (2011). Ethical Decision Making For Business. South- Western, Cengage Learning. [8]. Fritch, J., Petronio, S., Helft, P.R.,Torke, A. (2013). Making Decisions for Hospitalized Older Adults: Ethical Factors Considered by Family Surrogates. J Clin Ethics, 24(2), [9]. Goodpaster, K.E. (1992). Business ethics. In: L.C. Becker and Ch.B. Becker (eds.), Encyclopedia of Ethics, New York-London, vol. I, pp [10]. Jeurissen, R. (2011). Dilemma analysis. Accessible in Internet at: 35

12 [11]. Jox, R., Schaider, A., Marckmann, G., Borasio, G.D. (2012). Medical Futility at the End of Life: the Perspectives of Intensive Care and Palliative Care Clinicians. J Med Ethics, 38, [12]. Norman, W. (2013). Business Ethics. The International Encyclopedia of Ethics. Blackwell Publishing Ltd. [13]. Reich, WT. (1995). Introduction. In: Encyclopedia of Bioethics. New York: Simon and Schuster Macmillan; p. xxi. [14]. Solomon, R.C. (1992) Corporate Roles, Personal Virtues: an Aristotelian Approach to Business Ethics. Business Ethics Quarterly, Volume 2, Issue 3, [15]. Ten Have, H.A.M.J. (2001). Introduction. In: H.A.M.J. ten Have & B. Gordijn (eds.) Bioethics in European Perspective, (pp. 1-11).The Netherlands, Kluwer Academic Publishers. [16]. Trevino, L.K. and Nelson, K.A. (2011). Managing Business Ethics. Straight Talk About How To Do It Right. 5th ed. John Willey&Sons,Inc. [17]. Viafora, C. (1999). Toward a Methodology for the Ethical Analysis of Clinical Practice. Medicine, Health Care and Philosophy, 2, [18]. Weber, L. (2001). Business Ethics in Health Care. Beyond Compliance. Medical ethics series. David H. Smith and Robert M. Veatch (eds.) Indiana University Press. 36