Leadership for Health Professionals: Theory, Skills, and Applications, Third Edition
Gerald R. Ledlow and James H. Stephens
Chapter 10: Distributive Justice Exercise
1. Working with two to three (2 – 3) others (group of 3 – 4), find information from the
literature, governmental websites or educational institution websites and review the
following health policies:
a. Medicare
i. Medicare Part A
ii. Medicare Part B
iii. Medicare Part C or Medigap
iv. Medicare Part D (Pharmaceutical program)
b. Medicaid for your state
c. SCHIP Program for your state
d. EMTALA
e. The New OBAMA Healthcare Reform Plan
2. List the key tenets of the programs from #1 and the eligibility requirements (who can be
enrolled and use the program benefits) of each program.
3. List the stakeholders associated with the programs from #1.
4. Complete the following table based on what you know after group discussion.
Health Policy
Distributive Justice
Stakeholder
Stakeholder
Program
Theory(ies) Utilized
Resource Winner(s)
Resource Loser(s)
Medicare Part A
Medicare Part B
Medicare Part C
Medicare Part D
Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
Leadership for Health Professionals: Theory, Skills, and Applications, Third Edition
Gerald R. Ledlow and James H. Stephens
Medicaid
SCHIP
EMTALA
OBAMA Healthcare
Reform Plan
5. Defend with example why each Distributive Justice Theory(ies) were selected for each
program.
6. Given that access and utilization of health resources are scarce in society, what resource
did the ‘resource winner(s)’ stakeholders receive and what resource, and how was the
resource distributed, did the stakeholder ‘resource loser(s)’ have to give up?
Copyright © 2018 by Jones & Bartlett Learning, LLC, an Ascend Learning Company
Chapter 10
Ethics in Health
Leadership
“Healthcare executives should view ethics as a
special charge and responsibility to the patient,
client, or others served, the organization and its
personnel, themselves and the profession, and,
ultimately, but less directly, to society.”
American College of Healthcare Executives, 2009
Learning Objectives
• Define distributive justice, ethics, morals, and
values. Describe how they are used by leaders
in decision making.
• Explain four ethical principles that guide
decision making associated with patient care.
• Apply at least two ethical frameworks or
distributive justice theories, with examples of
moral practice of a leader, to an ethical issue in
a health organization.
Learning Objectives, cont.
• Analyze arguments and make a recommendation for
health leaders to adopt utilitarian and/or deontological
postures in their organization, and differentiate
potential decisions leaders would make between the
two frameworks to support your analysis and
recommendation.
• Compile a list of available options a leader in a health
organization has to develop for an integrated system of
ethics and moral practice, and summarize the potential
impact of each option regarding appropriate ethical
adaptation across the organization.
Learning Objectives, cont.
• Compare and contrast at least three ethical
frameworks or distributive justice theories for the
topics of patient autonomy, beneficence,
nonmaleficence, and justice, and interpret the
moral practice associated with those frameworks
(at least three) for a right-to-life issue and for the
practice of euthanasia.
Ethics in Health Leadership
• Ethics and the application of ethics, morality, are
leadership responsibilities.
– Too often, ethics, ethical practice, and discussions of ethics
are placed in a legal context of liability reduction and
“legalism.”
• Health organizational culture development that includes
an ethical framework, systems integrated in ethical
expectations, and moral practice of ethical actions and
behaviors are leadership responsibilities, not legal
counsel responsibilities.
– Health leaders model the behavior expected in the
organization; this especially includes being a moral actor.
What Is Ethics?
• Ethics is defined as a moral philosophy
between concepts of right and wrong behaviors
linked to resource allocation.
– It deals with values relating to human conduct with
respect to the rightness and wrongness of actions
and the “goodness” and “badness” of motives.
– Ethics in the health field can further be defined as
a set of moral principles and rules of conduct for
health professionals to follow.
What Is Ethics? cont.
• Ethics also can, at times, be culturally defined.
– This links back to distributive justice theories,
cultural values, and beliefs, and how a culture
selects and applies a model of resource allocation
based on societal norms and mores.
Difference Between Ethics,
Values, and Morals
• Values are enduring beliefs based on some
early form of indoctrination and experience.
– Values are learned from parents, the community,
school, peers, professional organizations, and
personal self-development, to name only a few
areas.
– Recall Rokeach’s model of values–beliefs–
attitudes.
Difference Between Ethics,
Values, and Morals, cont.
• Morals are applied practices derived from an
ethical framework that is based on values and
resource allocation beliefs. Different from values,
morals comprise the principals on which decision
making is based.
– Morality is the level of compliance to an ethical
framework.
– Morals are the actions and outcomes of the human
condition processed over time as evaluated against the
ethical framework based on values and resource
allocation principles.
The Difference Between Ethics,
Values, and Morals, cont.
• In Aesop’s fable of The Grasshopper and the Ants
– The “moral” of this story is that it is always best to
prepare for one’s future in the face of the uncertainty
of the environment. However, because this “lived
experience” may take an individual’s entire lifetime
to learn, the experience is shared through the lived
experience of others through moral tales.
Setting Ethical Standard in the
Health Organization
• Health leaders face ethical dilemmas in the daily work of
delivering health services and products within the health
organization.
• Health leaders may often find themselves torn between
owing allegiance to the financial stability of the organization
and the charitable nature of the health profession.
• Stakeholder expectations are expressed and integrated
through board of directors or board of trustees membership
that represents the communities served and the advocacy of
stakeholder expectations by senior leadership of the health
entity and within internal committee structures of the
organization, such as with the ethics committee.
Setting Ethical Standard in the
Health Organization, cont.
• The ethics committee has three main purposes:
education, consultation, and policy review.
– Challenges of the committee include internal organizational
principle conflict, values contradiction, leadership team
decision making, and community and industry ethical
attitudinal changes.
• The health organization should have an individual
appointed on staff as the resident ethicist to assist in
decision and policy making.
• The establishment of an ethics committee that meets on
a regular and reoccurring basis can likewise keep the
leadership informed of relevant and legitimate issues
confronting the health organization.
Ethics in Health Leadership
• Example: When actions and ethics collide
– During the financial collapse of many U.S.-based
organizations in the fall of 2008, Congress reacted
by providing over $700 billion to organizations
that had run themselves into the ground through
bad business practices and risky financial
behaviors. However, it was later learned that the
CEOs of many of these financially insoluble
organizations were still going to receive annual
bonus checks up to $620,000.
Common Ethical Dilemmas
• Common ethical dilemmas in health
organizations
– Ethical dilemmas in health organizations generally
arise out of professional, or values-based, conflicts
of interest.
– According to the American College of Healthcare
Executives, a conflict of interest occurs when one
has conflicting duties or responsibilities and meeting
one of them makes it impossible to meet the other.
The classic example occurs when a decision maker
for one organization is also a decision maker or
influence for another organization with which
business is transacted.
Relationship Morality
• Ethical dilemmas in the health organization are
inevitable. In the field of health leadership, ethical
dilemmas occur at three levels: micro, macro and
meso.
– The micro level involves individual issues, such as
relationships between individuals and leaders.
– The macro level involves societal or community issues
that reflect governmental actions or social policies.
These are typically culturally based.
– The meso level involves organizational or professional
issues.
Ethics in Health Leadership
• Business and financial ethics
• Contracts and negotiations
Ethics in Health Leadership, cont.
• Right to life issues
– Roe v. Wade
• Euthanasia
Ethics of Policy Making in U.S.
• Understanding the patient’s spirituality base in
decision making
– To adjust to the spiritual needs of patients entering the
health system, leaders should strive to be aware of the
diverse beliefs within their organizations and foster a
high degree of sensitivity and respect for those beliefs.
– Specific beliefs and practices to consider include, but
are not be limited to:
•
•
•
•
•
Healing rituals
Dying, death, and care of dead bodies
Harvesting and transplanting organs
End of life and right to life decisions
Use of reproductive technologies
Ethical Codes Adopted by Health Industry
• Two of these theories are contrasting frameworks:
utilitarianism and deontology.
• Issues surrounding patient rights of autonomy,
beneficence, nonmalificence, and justice
important as well.
• Common ethical codes or frameworks should be
integrated with the cost, quality, and access
paradigm considering changes to the health
system or resource allocation of health resources.
Distributive Justice
• At the foundation of ethics is distributive
justice.
– Distributive justice is a set of theories or ideologies
that attempt to instill a set of values, ideals of
fairness based on those values, and beliefs in the
allocation of resources, food, water, housing,
wealth/money, opportunities, materials, etc.,
throughout a society.
Distributive Justice, cont.
• At its root, ethics is a framework that is based
on a distributive justice theory or combination
of those theories; ethics is an extension of
resource allocation and the methods of that
allocation while morality or morals is the level
of congruence to that ethical framework.
Utilitarianism
• Utilitarianism is a theory that takes as its
primary aim the attainment of maximum
possible happiness of a society as a whole.
• This goal is to be achieved in such a way that
one first checks what makes every particular
individual in a society happy, then sums up all
these various wants and preferences, and
finally finds out how to satisfy the greatest
number of them.
Egalitarianism
• Egalitarianism is a set of closely related
theories that without exemption advocate the
thesis that all members of a society should
have exactly equal amount of resources.
Libertarianism and Deontology
• Libertarianism
– Libertarianism suggests that the market or market
forces should determine the distribution of
resources in a society.
• Deontology
– Deontology is the opposite of utilitarianism. It is
an ethical framework and philosophy of resource
allocation that suggests actions should be judged
right or wrong based on their own values and
principle driven characteristics.
Pluralism
• Pluralists hold that goods that are normally
distributed in any society are too different to
be distributed according to only one criterion.
To almost every one of these various kinds of
goods we should apply a criterion that is
characteristic for it. Thus we have diverse
spheres of justice in which there are different
criteria that tell us which distributions are
morally right.
Autonomy, Beneficence,
Nonmaleficence, and Justice
• Autonomy: The patient's right to self
governance and medical decision making
• Beneficence: The requirement of the health
organization to do “good”
• Nonmaleficence: The requirement for the
health organization to do no harm
• Justice: The obligation to give each patient fair
resource allocation (services and products
associated with the care process)
Difference Between Medical Ethics,
Clinical Ethics, and Bioethics
• Clinical ethics refers to the ethics of the clinical
practice of medicine and with ethical problems
that arise in the care of patients.
– Includes traditional professional medical ethics that
place the patient at the center of consideration.
• Traditional medical ethics were deficient in the
face of technological advances of recent years;
this reality has giving rise to bioethics.
– Bioethics’ first concern is with “the intersection of
ethics and the life sciences” and later expanded to
include human values.
Difference Between Medical Ethics,
Clinical Ethics, and Bioethics, cont.
• Health organizations have to balance and
develop systems to adhere to medical and
clinical ethical standards as well as bioethical
standards.
Health Leaders Are Part Ethicist
Steps to ensuring ethical framework in health
organization:
• Establishing and chartering ethics committees with
authority
• Requiring staff attendance, participation, and evaluation
of education programs
• System of policy development and review
• Seeking consultation by utilizing consultants with
similar values and moral practices
• Integrating professional, clinical, and business ethical
performance through leader role modeling and
subordinate reinforcement (rewards and punishments)
Health Leaders Are Part Ethicist, cont.
• Fostering a positive ethical climate within an
open and supportive communication environment
(For example, it is acceptable to tell leadership
about a mistake of error.)
• Reviewing relationships with external
stakeholders, partners, and entities with which the
health organization has contract relationships to
evaluate ethical framework and moral practice
congruence with the health organization
Health Leader’s Challenge: Where to Start?
Questions for health leaders to consider when
creating ethics system in their organizations:
• Which values does the organization hold?
• On what distributive justice theoretical framework
should ethical decisions be based?
– Does that framework apply to all situations and if not,
when does the framework not apply and what framework
takes its place?
− How do values of the health organization get put into
practice?
Health Leader’s Challenge, cont.
• How does a health organization establish an
ethical framework and moral application of
principles (planning, group discussions,
professional associations, laws and regulations,
community expectations, community needs, etc.)?
• Does the health organization have an ethical
statement or creed highly visible and accessible
by all stakeholders?
Health Leader’s Challenge, cont.
• To embed the ethical foundation and moral actions,
which systems need to be in place, such as committees,
policies, procedures, enforcement of those policies and
procedures (consider: should coupling be tight or loose
regarding ethical frameworks and moral behavior and
actions?), and leadership role modeling considering
customers’/patients’ expectations, business conduct and
operations, negotiations, contract agreements and
compliance, legal/regulation compliance, error
remediation (how do you resolve errors made?), and
health service and/or product delivery?
• How can leadership decisions remain consistent to the
ethical framework over time? How do you know you
are consistent?
Health Leader’s Challenge, cont.
• How can organizational culture incorporate the
ethical framework and moral application of
principles the health organization holds
important?
• How does the health organization integrate its
ethical framework and moral applications into its
strategic planning, decision making, and daily
operations?
Health Leader’s Challenge, cont.
• How does the health organization integrate its
ethical framework and moral application into the
communities they serve and to the interface and
external stakeholders of the health organization?
• How does the health organization ensure internal
staff and subordinate adaptation to the ethical
framework and moral application of that
framework (training, annual updates, rewards and
punishments, etc.) to long-term employees and to
new employees (orientation, training, etc.)?
Health Leader’s Challenge, cont.
• Who keeps the health leadership team
accountable to the ethical framework and moral
application of established principles?
• Is the ethical framework and moral application of
those principles reasonable, relevant, and
realistic? How are boundaries established?
Health Leader’s Challenge, cont.
• Who (individuals, groups, legal counsel, etc.) has
the authority to initiate an ethical incident report,
an ethical discussion, an ethical incident
investigation, an ethically attributed reward or
punishment? Is the health organization legally or
liability oriented to ethical considerations,
leadership oriented, or both? (What may be
legally “moral” to limit liability may not be
leadership “moral” to do what is right.)
Regulatory Compliance
• Much integrates with governmental payment
(reimbursement with taxpayer funds) as part of
fiduciary responsibility.
• Much deals with private/personal financial
gain done outside the care process.
• How does the example organization create a
system of regulatory compliance?
Discussion Questions
• Define distributive justice, ethics, morals,
values, and conflict of interest. Can you
describe how they are used by health leaders in
decision making?
• Explain four ethical principles that guide
decision making associated with patient care.
How can leaders use these principles in
decision making with a health organization?
Discussion Questions, cont.
• How could you apply at least two ethical
frameworks or distributive justice theories, with
examples of moral practice of a leader, to an
ethical issue in a health organization? What would
be the results?
• Should health leaders adopt utilitarian and/or
deontological postures in their organization? How
could you differentiate potential decisions leaders
would make between the two frameworks?
Discussion Questions, cont.
• What available options does a leader in a health
organization have to develop for an integrated system
of ethics and moral practice? What would be the
potential impact of each option regarding appropriate
ethical adaptation across the organization?
• How would the utilization of at least three different
ethical frameworks (distributive justice theories) react
with regard to patient autonomy, beneficence,
nonmaleficence, and justice? How would the
application of moral practice associated with those
frameworks (at least three) be different for a right-tolife issue and for the practice of euthanasia?
Exercises
• Define distributive justice, ethics, morals, and
values. Describe how they are used by leaders in
decision making in one page or less.
• Explain four ethical principles that guide decision
making associated with patient care in one page
or less.
• Apply at least two ethical frameworks or
distributive justice theories, with examples of
moral practice of a leader, to an ethical issue in a
health organization in two pages or less.
Exercises, cont.
• Analyze arguments and make a
recommendation for health leaders to adopt
utilitarian and/or deontological postures in
their organization, and differentiate potential
decisions leaders would make between the two
frameworks to support your analysis and
recommendation in two to three pages.
Exercises, cont.
• Compile a list of available options a leader in a
health organization has to develop for an
integrated system of ethics and moral practice,
and summarize the potential impact of each
option regarding appropriate ethical adaptation
across the organization in one to two pages.
Exercises, cont.
• Read the Case Study of the Transferred Employee in
the text and answer the following questions in two to
three pages.
–
–
–
–
–
–
What do you do?
Do you change the documents?
Do you go back and confront your supervisor?
What is your decision and why did you make it?
What is your next course of action?
What other factors do you consider and what other actions
do you take?
– Which ethical framework or distributive justice theory best
supports your decisions regarding the case and why?
Purchase answer to see full
attachment