HEC Forum DOI 10.1007/s10730-014-9235-7
Framework for Ethical Decision-Making Based on Mission, Vision and Values of the Institution Jaro Kotalik • Cathy Covino • Nadine Doucette Steve Henderson • Michelle Langlois • Karen McDaid • Louisa M. Pedri
•
Ó Springer Science+Business Media Dordrecht 2014
Abstract The authors led the development of a framework for ethical decisionmaking for an Academic Health Sciences Centre. They understood the existing mission, vision, and values statement (MVVs) of the centre as a foundational assertion that embodies an ethical commitment of the institution. Reflecting the Patient and Family Centred Model of Care the institution is living, the MVVs is a suitable base on which to construct an ethics framework. The resultant framework consists of a set of questions for each of the MVVs. Users of the framework are expected to identify two or more possible decisions to address the issue at hand and then, by applying the provided sequence of questions to each, examine these options and determine the overall ethically preferable decision. The construction of such a framework requires the creative involvement of the institution’s staff. Thus the development of the framework can represent a training process in ethical decisionmaking as well as advance the ethical atmosphere of the institution. This novel approach has the advantage of placing the MVVs on active duty, at the centre of ethical decision-making, and lifts it from its otherwise relative obscurity in most institutions. Keywords Ethical decision-making Ethics framework Organization’s mission, vision and values
J. Kotalik (&) Thunder Bay Regional Health Sciences Centre and Centre for Health Care Ethics Lakehead University, Thunder Bay, ON, Canada e-mail: [email protected] C. Covino N. Doucette S. Henderson M. Langlois K. McDaid Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada L. M. Pedri Centre for Health Care Ethics Lakehead University, Thunder Bay, ON, Canada
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Introduction The purpose of this paper is to describe a novel approach in developing a framework for ethical decision-making in a health sciences centre. We believe that a framework generated from the mission, vision and values statement (MVVs) can be more integral to the overall moral commitment of the institution and have a greater potential to enhance the ethical quality of interactions between patients, staff, clients and the community that it serves. The terms ‘‘ethics framework,’’ ‘‘ethical framework,’’ and ‘‘framework for ethical decision-making’’ are increasingly being used in our health care institutions. This can be attributed to the growing recognition of the centrality of ethics to health care delivery and development of organizational ethics. More pragmatically, the increase in use is likely related to the fact that bodies providing accreditation of health care institutions are focusing on health care ethics as a way to examine and improve the quality of health services. Accreditation Canada included an ‘‘ethics’’ requirement in accreditation standards in 2001 and revised them in 2008. In its 2012 standards, Accreditation Canada placed a group of ethics-related requirements at the forefront of their expectations concerning leadership of organizations seeking their seal of approval. Standard 1.4 states: ‘‘The organization’s leaders develop and implement an ethics framework to support ethical practice’’ (Accreditation Canada 2012). The Joint Commission, which provides accreditation in the United States, is also asking those organizations seeking endorsement if an ethics framework is in place for the organization (Joint Commission Resources 2013). Background and Literature Survey Currently, the term ‘‘ethics framework’’ is used mainly to mean one of two things. It can refer to a tool, a model or a set of algorithms that facilitates the ethical analysis of an action or a decision in an orderly, systematic manner. The term can also mean such a tool plus other documents, codes, statements, standards, policies, committees, structures, and education and consulting activities that are meant to assist the organization and its staff to make the best possible ethical decisions. In this paper, we will be discussing ‘‘ethics framework’’ in the first, narrower sense. Such frameworks, or models that are meant to assist ethical decision-making, are not new. The first edition of one of the first popular texts of bioethics, written by Jonsen, Siegler and Winslade in 1982, identified four topics that are essential to every clinical situation and created a model that is now known as the ‘‘Four-Topics’’ method or a ‘‘4-Box’’ approach (Jonsen et al. 2006). This approach to organizing pertinent facts of a particular case remains popular and is used alone (Sokol et al. 2011), as a first section of a comprehensive decision-making tool (McDonald et al. 2001), or in combination with multiple procedural steps, principles, values and considerations (Nor-Man Regional Health Authority 2005; Ontario Shores Centre for Mental Health Sciences 2013; Northwest Association for Biomedical Research 2013). One of the more complex frameworks offers four procedural steps, three of the four ‘‘boxes’’ of Jonsen et al. to identify relevant facts, and five conditions drawn from priority-setting tools. Finally, the user of this framework is invited to select
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relevant ethical propositions from the list of 18 principles and values (Trillium Health Centre 2013). Many frameworks consist of a set of procedural steps only (Kirby 2013; Vancouver Island Health Authority 2013), while others combine procedural steps with some ethical values and principles (Centre for Clinical Ethics 2013; Queensway Carlton Hospital 2013). Some frameworks consist of procedural steps and ethical values drawn from a professional code of ethics (College of Nurses of Ontario 2009). Other documents labelled ‘‘framework’’ invite those who need to make an ethical decision to consider in sequence a variety of possible approaches based on different ethical theories, such as the utilitarian approach, the rights approach, the justice approach, the common good approach and the virtue approach (Velasquez et al. 2013; Center for Ethical Deliberations, University of Northern Colorado 2005–2007). One on-line resource lists eleven different frameworks or ethical decision-making models (Wellington 2009). We have not found any publications that compare frameworks on theoretical or practical grounds or publications reporting on the frequency with which health care workers use those frameworks which their institutions provide. We are also not aware of any report or evaluation of the efficacy or practical usefulness of frameworks.
Method Thunder Bay Regional Health Sciences Centre (TBRHSC) is an Academic Health Science Centre with 375 beds and more than 100,000 Emergency Department visits annually, serving the needs of people living in the city of Thunder Bay and the region of Northwestern Ontario, Canada (population of 250,000). The Centre is affiliated with the Northern Ontario School of Medicine. The Board of Directors of TBRHSC expressed a desire for a framework for ethical decision-making. The Bioethics Consultant (JK) met with Senior Management and the Board to explore how best to proceed. Discussion centered on the range of issues to which the decisions-making framework could be applied and on the usefulness of such an instrument in daily situations when decisions need to be made under time constraints and also well understood by others. The framework would provide a basis on which they could support their decisions. There was an agreement that the framework should be a tool useful for decision-making at all levels of TBRHSC, from the Board of Directors to the nursing units, and that it should be simple and practical so that using it would not require special training. The proposal of the Ethics Consultant and an associate (JK, LP) to create a framework based on the TBRHSC’s MVVs was accepted by the Board. Three Board members (ND, SH, KM) were appointed to work with the Ethics Consultant and were joined by the Senior Manager responsible for ethics (CC) and the Patient Safety Lead (ML) in developing a draft of the framework. The group started its work in January 2012 by reviewing selected literature on ethics frameworks and the role of principles and values in decision-making. Next, the group discussed the meaning of the ethical content of the Board’s statement of
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MVVs. Subsequently, the group started to generate multiple questions for each of the TBRHSC’s stated vision, mission and values, intended to determine whether a certain proposed decision or a course of action is compatible with these basic ethical statements. As the group debated the questions’ validity, clarity and applicability, some questions were eliminated, and others were combined or modified. The goal was to define 3–5 questions for each of the four declared values of TBRHSC (patients first, accountability, respect, excellence) so that the framework would be brief, but also thorough enough to assure that these selected questions reasonably assessed whether an option respected the particular value. Only one question was constructed for the mission and vision of the Centre. The group held three meetings of 1–2 hours duration. Between meetings, members communicated by email to comment on and modify various drafts of the framework. The resulting draft was presented to the whole Board of Directors and to the senior management group and further edited based on the discussion. The framework was presented to the Ethics Team of the Centre for additional input. The final version of the framework was placed in a format that provided space for users to record their responses next to questions. The framework was successfully used at two meetings of the Board of Directors to evaluate various courses of action and subsequently distributed to the Senior Management Council. An evaluation of the framework in the organization is underway.
Results The resultant framework consists of one question on the mission and vision and 21 questions on values that the Centre previously adopted. These are listed in Table 1. The leading question for each of the four values (printed in bold in the Table 1) is to be used as a first approach to decision making and for that reason these four questions are embedded on the bottom of the agenda template of the Board and Senior Management Council as well as on the briefing note template. When needed, the decision-making body is expected to consult all 21 questions. The initial reaction of users has been favourable. The Board of Directors and Senior Management Council used the template to discuss and take a position on several sensitive issues, namely, the implementation of non-smoking policy on the grounds of the institution, the process for management of patients requiring alternative level of care and the surge capacity plan. Participants felt that the use of the ethics framework lead to thorough and balanced examination of issues and to a greater satisfaction with the decision-making process.
Discussion For a number of decades it has been customary for governing bodies of health care organizations to develop and proclaim the organization’s MVVs. The word ‘‘ethics’’ may not appear in these documents, but values selected are invariably ethical values and these documents can be seen as an ethical commitment of the organizations to
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HEC Forum Table 1 Framework for Ethical Decision- Making Mission: To advance world-class Patient and Family Centred Care in an academic, research-based, acute care environment. Vision: Healthy Together
Question:
Values:
Questions:
A. Patients ARE first:
1. Does the course of action address a significant need of our patients or our community?
Respond respectfully to needs & values of patients and families
B. Accountability: Advance quality, safety and Patient and Family Centred Care & be accountable for delivering fiscally responsible services
O yes
Does the Course of Action Uphold the Hospital Mission and Vision?
O partially O no
O yes O partially O no
2. Was there a fair consultation process about the course of action, including representation of those who are disadvantaged or unable to speak for themselves?
O yes
3. Have we engaged the patients and families in dialogue, using language that they understand and encouraging open and honest expression of opinions?
O yes
4. Is the course of action guided by values of patients and families, esp. those most affected and most vulnerable?
O yes
5. Would this course of action be defensible as ‘‘putting patients first’’ under tough scrutiny in the public forum?
O yes
1. Will the course of action improve safety and reduce risks for patients or could the course of action possibly have an opposite effect?
O yes
2. Is the course of action expected to increase the quality of care?
O yes
O partially O no O partially O no O partially O no O partially O no O partially O no O partially O no
3. Does this course of action create a fiscal impact on our organization?
O yes O partially O no
4. Is there a fiscal impact compatible with other important fiscal commitments?
O yes O partially O no
5. Does the course of action represent prudent use of resources allocated wisely on the basis of fair and publicly- defensible reasons and procedures?
O yes
6. Will the course of action promote the public’s trust in our organization?
O yes
O partially O no O partially O no
C. Respect We honour the uniqueness of every individual
1. Does this course of action demonstrate due consideration for the dignity and rights of others?
O yes O partially O no
2. Was there an effective process to learn about the uniqueness of every individual? (e.g. those who are hearing impaired, those for whom English is not their first language, and those with mental illness)
O yes O partially O no
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D. Excellence We are recognized leaders in Patient and Family Centered Care through the alignment of Academics and Research with Clinical Services.
3. Is the course of action sensitive to the needs, interests, feelings and preferences of patients, which are diverse and can be influenced by a range of factors, including cultural, religious and socioeconomic backgrounds?
O yes
4. Does the course of action negatively impact on another population or result in favouritism or reverse discrimination?
O yes
5. Does the course of action provide a reasonable accommodation of individual needs and preferences of our patients? (i.e., aboriginal healing practices)
O yes
1. Will the outcome of this course of action surpass ordinary requirements or standards?
O yes
O partially O no
O partially O no O partially O no O partially O no
2. Was a reasonable evaluation of the evidence conducted and does it support this course of action?
O yes O partially O no
3. Does this course of action support ‘‘Best Practice’’; that is, the practice that has proven to be most effective in providing a specific outcome?
O yes
4. Will the course of action advance the hospital as a leader in patient and family centred care?
O yes
O partially O no O partially O no
5. Does the course of action encourage and support learning and/or research?
O yes O partially O no
their patients, clients, staff and the population. MVVs appear in annual reports, on organizations’ websites and in other formal documents; framed copies of MMVs may be placed on walls of staff rooms and corridors. However, it is uncertain to what degree the staff of the organization is familiar with these statements and how much influence they have on the operation of the organization. Researchers who examined ethics frameworks of another kind, those found in strategic policy documents, concluded that it is unclear whether these frameworks function possibly only as ‘‘aesthetic frames’’ to make policies appear ethical (Giacomini et al. 2009). Similar concerns can be raised about the frameworks of health care institutions. We did not find any publications that reported comparisons between the values incorporated in MVVs and the values that were used in the same organization to construct a framework for ethical decision-making. These two sets of values are usually created at different levels of the organizations. In Canada, MVVs are usually composed by the board of directors, while frameworks for ethical decision-making are created by ethics consultants or committees. We found only a few instances in which frameworks refer to MVVs. In one organization, the proposed framework promotes the use of ‘‘four-boxes’’ to gather facts, and then suggests that ethical analysis should be undertaken ‘‘in view of the MVVs,’’ but also ‘‘in light of established bioethical principles.’’ No further details are provided (Ethics Services at Providence Health Care 2012). Another organization created a 22-page, complex,
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multilayered ‘‘Ethics Framework’’ that contains one paragraph on the organization’s MVVs. These are proposed to be foundations for ethical decision-making, together with nine other principles and considerations (legislation; relationships, teamwork and communication; veracity and fidelity; utility; justice; confidentiality and privacy; virtues and reflective practice; respect for diversity and context) (Hamilton Health Sciences 2010). Finally, a framework that consists of eight procedural steps also lists ‘‘organizational mission/values’’ as one of the principles to be used for ranking decision alternatives (Coughlin 2002). We could find no communications or publications reporting that an institution’s MVVs were used as a sole or privileged basis of an ethical decision-making framework for the organization, as we have done. Some advantages of creating a framework using the process described here are obvious. If the ethical decision-making framework is based on the MVVs already adopted by the organization, it increases the likelihood that the organization’s MVVs will actually guide ethical decision-making. In addition, by trying to apply declared values in actual situations, the organization’s MVVs itself will be subject to scrutiny; if the statement does not fit the organization, if it contains too many internal contradictions or is incomplete, these deficiencies will become apparent. Staff could then build momentum within the organization to modify the MVVs. Another advantage of a framework based on MVVs is that such a framework will use the language and terms which are already in circulation in the organization, and this may make such framework more readily approved and used by management and staff. It may be that the importance of any decision-making framework is not even so much in the document itself, but in the process of developing it, educating the staff about it, and monitoring its use. All these activities can lead to increased staff engagement in the recognition, discussion and where possible, resolution of ethical issues in day-to-day work. We do not claim that the questions we have generated for our framework are the only or the best way to test if a certain decision option is expressing or supporting the set of values of our organizations. If the same process were carried out in another organization, even one based on the same values, entirely different questions might emerge, because the questions are likely linked to specific problems, tensions or successes that the organization has experienced. Even if several groups of board and staff members in one organization were to undertake this exercise, several sets of questions may emerge because of the personal background and experience of the individuals involved. Empirical research into the process by which frameworks are, or could be created and used would be a useful topic for future studies. A possible risk of our approach to the development of an organization’s ethical framework could materialize if the organization’s declared MVVs do not fit the organization, and the moral atmosphere of the organization is such that no one cares or feels permitted to raise the issue of their inadequacy. In this case, a decisionmaking framework based on MVVs could be unhelpful or even misleading. Another objection to our approach could be that such a simple framework trivializes the difficulty of making ethical decisions, which surely need to take into account more than simply an organization’s mission, vision and four values. In response, we suggest that the framework is an instrument to open discussion and can facilitate a
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decision but should never be considered a final, precise tool that somehow automatically generates a ‘‘correct’’ decision. Objections could be raised that our framework does not distinguish between organizational and clinical ethical decision-making. We note that some of the questions of our framework are more relevant to one or the other type of issues arising in health care institutions; however, clear distinctions between organizational and clinical ethics often cannot be made (Bean 2011), and it would be counterproductive to have two separate frameworks. It should be noted that our framework was not designed to promote any numerical evaluation of responses, averaging, scoring or creating a threshold of acceptability. We feel that a global assessment of responses to all questions, performed separately for each decision option, gives the person or a group using it a good general idea of those options that are clearly inappropriate and those that may be ethically preferable. We also see the possibility that our framework could miss some morally significant aspect of the situation or decision options, and that the final decision may not always be made only from the framework. Sometimes, in evaluating various options for action, a deeper, not immediately apparent moral commitment may emerge that points toward a decision option that the framework does not favor. For example, an organization’s MVVs and framework may strongly support a decision option that fully respects a client’s autonomy. However, when a specific client’s capacity is borderline, health care workers may feel obliged to act on their own interpretation of the client’s best interest. Even then, using the framework can be helpful, because of its ability to unearth unarticulated agendas and commitments. This may also lead the users to further research the area of concern to ensure it is ethically sound. Ideally, an ethics decision-making instrument should be evaluated to determine how it is used in the organization and how it meets the needs and expectations of users. However, we did not find in the published literature any such evaluation of frameworks for ethical decision-making created for hospitals and similar institutions. Our group has undertaken an evaluation of our framework at the Senior Management Council level with a Board evaluation to follow. Various levels of our organization will begin using the framework if the evaluation is favourable.
Conclusions If a health care institution wishes to develop a framework for ethical decisionmaking and has already adopted a MVVs, the framework could be based on this basic ethical commitment. A working party of Board and staff members may generate a set of questions to be used to decide on ethical suitability of any decision option. A framework created in this way may be simple enough to be used in a variety of health care settings and may help to make a connection between the organization’s declared MVVs and its day-to-day operation. Acknowledgments Many thanks to Loretta Delea and Wendy Lange for administrative support and to Marion Agnew for editorial assistance.
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References Accreditation Canada. (2012). Qmentum Program. Leadership Standards. Ottawa. May 28, 2012. Bean, S. (2011). Navigating the murky intersection between clinical and organizational ethics: A hybrid case taxonomy. Bioethics, 25(6), 320–325. Center for Ethical Deliberation, University of Northern Colorado. (2005–2007). Frameworks. Retrieved April 1, 2013, from http://mcb.unco.edu/ced/frameworks/. Centre for Clinical Ethics, Toronto. (2013). A principle based framework/process for ethical decision making. Retrieved March 31, 2013, from http://www.stjoe.on.ca/patients/pdf/framework.pdf. College of Nurses of Ontario. (2009). Practice standard. Retrieved March 30, 2013, from http://cno.org/ Global/docs/prac/41034_Ethics.pdf?eps;anguage=en. Coughlin, M. D. (2002). A framework for making ethical decisions in health care. St. Joseph’s Health System. Retrieved April 3, 2013, from http://www.smgh.ca/wp-content/uploads/2012/01/AFramework-for-Making-Ethical-Decisions-in-Health-Care.pdf. Ethics Services at Providence Health Care. (2012). The framework for ethical decision-making. Retrieved April 1, 2013, from http://www.providencehealthcare.org/ethics_services/decision-makingframework.html. Giacomini, M., Kenny, N., & DeJeans, D. (2009). Ethics frameworks in Canadian health policies: foundation, scaffolding, or window dressing? Health Policy, 89(1), 58–71. Hamilton Health Sciences Centre. (2010). Ethics framework. Retrieved April 1, 2013, from http:// hamiltonhealthsciences.ca/workfiles/CLINICAL_ETHICS/HHSEthicsFramework.pdf. Joint Commission Resources. (2013). Ethics framework. Retrieved April 18, 2013, from http://www. jcrinc.com/Chapter-1-Defining-Main-Components/Developing-and-Implementing-an-Ethical-Infras/ Ethics-Framework/. Jonsen, A., Siegler, M., & Winslade, W. (2006). Clinical Ethics: a practical approach to ethical decision making in clinical medicine (6th ed.). New York: McGraw Hill Professional. Kirby, J. (2013). Ethics decision-making framework. South West Health. Retrieved March 31, 2013, from http://www.swndha.nshealth.ca/pages/Ethics%20Decision-Making%20Framework2008.pdf. McDonald, M. (with Rodney, P., & Starzomski, R.). (2001). A framework for ethical decision-making: Version 6.0. Retrieved April 18, 2013, from http://www.ethics.ubc.ca/upload/A%20Framework% 20for%20Ethical%20Decision-Making.pdf. Nor-Man Regional Health Authority. (2005). Framework for ethical decision-making. Retrieved April 18, 2013, from http://www.norman-rha.mb.ca/documents/EthicsFramework_000.pdf. Northwest Association for Biomedical Research, Seattle, WA. (2013). Decision-making frameworks. Retrieved April 3, 2013, from http://nwabr.org/sites/default/files/DMF.pdf. Ontario Shores Centre for Mental Health Sciences. (2013). Clinical ethical decision-making framework. Retrieved April 3, 2013, from http://www.ontarioshores.ca/about_us/our_approach/ethical_ decision_making/. Queensway Carleton Hospital. (2013). Ethical framework. Retrieved April 14, 2013, from http://www. qch.on.ca/Home.aspx?PageId=535. Sokol, D. K., McFadzean, W. A., Dickson, W. A., & Whitaker, I. S. (2011). Ethical dilemmas in the acute setting: A framework for clinicians. BMJ. doi:10.1136/bmj.d5528. Trillium Health Centre. (2013). The IDEA: Ethical decision making framework. Retrieved March 31, 2013, from http://www.trilliumhealthcentre.org/about/documents/TrilliumIDEA_EthicalDecision MakingFramework.pdf. Vancouver Island Health Authority. (2013). A generic framework for ethical decision making. Retrieved March 13, 2013, from http://www.viha.ca/NR/rdonlyres/13229200-51A3-4296-AD13-0FC431F4D0 48/0/a_generic_framework_for_ethical_decision_making.pdf. Velasquez, M., Andre, C., Shanks, T., & Myer, M. J. (2013). Thinking ethically: A framework for moral decision making. Markkula Centre for Applied Ethics at Santa Clara University. Retrieved March 31, 2013, from http://www.scu.edu/ethics/practicing/decision/thinking.html. A condensed version of this framework is used by Vancouver Island Health Authority in combination with procedural steps. Retrieved March 31, 2013, from http://www.viha.ca/NR/rdonlyres/13229200-51A3-4296-AD130FC431F4D048/0/a_generic_framework_for_ethical_decision_making.pdf. Wellington, A. (2009). Sample ethical decision making models. Ryerson University, Toronto. Retrieved March 31, 2013, from http://www.ryerson.ca/ethicsnetwork/resources/ethicaldecision/.
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Framework for Ethical Decision-Making Based on Mission, Vision and Values of the Institution Jaro Kotalik • Cathy Covino • Nadine Doucette Steve Henderson • Michelle Langlois • Karen McDaid • Louisa M. Pedri
•
Ó Springer Science+Business Media Dordrecht 2014
Abstract The authors led the development of a framework for ethical decisionmaking for an Academic Health Sciences Centre. They understood the existing mission, vision, and values statement (MVVs) of the centre as a foundational assertion that embodies an ethical commitment of the institution. Reflecting the Patient and Family Centred Model of Care the institution is living, the MVVs is a suitable base on which to construct an ethics framework. The resultant framework consists of a set of questions for each of the MVVs. Users of the framework are expected to identify two or more possible decisions to address the issue at hand and then, by applying the provided sequence of questions to each, examine these options and determine the overall ethically preferable decision. The construction of such a framework requires the creative involvement of the institution’s staff. Thus the development of the framework can represent a training process in ethical decisionmaking as well as advance the ethical atmosphere of the institution. This novel approach has the advantage of placing the MVVs on active duty, at the centre of ethical decision-making, and lifts it from its otherwise relative obscurity in most institutions. Keywords Ethical decision-making Ethics framework Organization’s mission, vision and values
J. Kotalik (&) Thunder Bay Regional Health Sciences Centre and Centre for Health Care Ethics Lakehead University, Thunder Bay, ON, Canada e-mail: [email protected] C. Covino N. Doucette S. Henderson M. Langlois K. McDaid Thunder Bay Regional Health Sciences Centre, Thunder Bay, ON, Canada L. M. Pedri Centre for Health Care Ethics Lakehead University, Thunder Bay, ON, Canada
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Introduction The purpose of this paper is to describe a novel approach in developing a framework for ethical decision-making in a health sciences centre. We believe that a framework generated from the mission, vision and values statement (MVVs) can be more integral to the overall moral commitment of the institution and have a greater potential to enhance the ethical quality of interactions between patients, staff, clients and the community that it serves. The terms ‘‘ethics framework,’’ ‘‘ethical framework,’’ and ‘‘framework for ethical decision-making’’ are increasingly being used in our health care institutions. This can be attributed to the growing recognition of the centrality of ethics to health care delivery and development of organizational ethics. More pragmatically, the increase in use is likely related to the fact that bodies providing accreditation of health care institutions are focusing on health care ethics as a way to examine and improve the quality of health services. Accreditation Canada included an ‘‘ethics’’ requirement in accreditation standards in 2001 and revised them in 2008. In its 2012 standards, Accreditation Canada placed a group of ethics-related requirements at the forefront of their expectations concerning leadership of organizations seeking their seal of approval. Standard 1.4 states: ‘‘The organization’s leaders develop and implement an ethics framework to support ethical practice’’ (Accreditation Canada 2012). The Joint Commission, which provides accreditation in the United States, is also asking those organizations seeking endorsement if an ethics framework is in place for the organization (Joint Commission Resources 2013). Background and Literature Survey Currently, the term ‘‘ethics framework’’ is used mainly to mean one of two things. It can refer to a tool, a model or a set of algorithms that facilitates the ethical analysis of an action or a decision in an orderly, systematic manner. The term can also mean such a tool plus other documents, codes, statements, standards, policies, committees, structures, and education and consulting activities that are meant to assist the organization and its staff to make the best possible ethical decisions. In this paper, we will be discussing ‘‘ethics framework’’ in the first, narrower sense. Such frameworks, or models that are meant to assist ethical decision-making, are not new. The first edition of one of the first popular texts of bioethics, written by Jonsen, Siegler and Winslade in 1982, identified four topics that are essential to every clinical situation and created a model that is now known as the ‘‘Four-Topics’’ method or a ‘‘4-Box’’ approach (Jonsen et al. 2006). This approach to organizing pertinent facts of a particular case remains popular and is used alone (Sokol et al. 2011), as a first section of a comprehensive decision-making tool (McDonald et al. 2001), or in combination with multiple procedural steps, principles, values and considerations (Nor-Man Regional Health Authority 2005; Ontario Shores Centre for Mental Health Sciences 2013; Northwest Association for Biomedical Research 2013). One of the more complex frameworks offers four procedural steps, three of the four ‘‘boxes’’ of Jonsen et al. to identify relevant facts, and five conditions drawn from priority-setting tools. Finally, the user of this framework is invited to select
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relevant ethical propositions from the list of 18 principles and values (Trillium Health Centre 2013). Many frameworks consist of a set of procedural steps only (Kirby 2013; Vancouver Island Health Authority 2013), while others combine procedural steps with some ethical values and principles (Centre for Clinical Ethics 2013; Queensway Carlton Hospital 2013). Some frameworks consist of procedural steps and ethical values drawn from a professional code of ethics (College of Nurses of Ontario 2009). Other documents labelled ‘‘framework’’ invite those who need to make an ethical decision to consider in sequence a variety of possible approaches based on different ethical theories, such as the utilitarian approach, the rights approach, the justice approach, the common good approach and the virtue approach (Velasquez et al. 2013; Center for Ethical Deliberations, University of Northern Colorado 2005–2007). One on-line resource lists eleven different frameworks or ethical decision-making models (Wellington 2009). We have not found any publications that compare frameworks on theoretical or practical grounds or publications reporting on the frequency with which health care workers use those frameworks which their institutions provide. We are also not aware of any report or evaluation of the efficacy or practical usefulness of frameworks.
Method Thunder Bay Regional Health Sciences Centre (TBRHSC) is an Academic Health Science Centre with 375 beds and more than 100,000 Emergency Department visits annually, serving the needs of people living in the city of Thunder Bay and the region of Northwestern Ontario, Canada (population of 250,000). The Centre is affiliated with the Northern Ontario School of Medicine. The Board of Directors of TBRHSC expressed a desire for a framework for ethical decision-making. The Bioethics Consultant (JK) met with Senior Management and the Board to explore how best to proceed. Discussion centered on the range of issues to which the decisions-making framework could be applied and on the usefulness of such an instrument in daily situations when decisions need to be made under time constraints and also well understood by others. The framework would provide a basis on which they could support their decisions. There was an agreement that the framework should be a tool useful for decision-making at all levels of TBRHSC, from the Board of Directors to the nursing units, and that it should be simple and practical so that using it would not require special training. The proposal of the Ethics Consultant and an associate (JK, LP) to create a framework based on the TBRHSC’s MVVs was accepted by the Board. Three Board members (ND, SH, KM) were appointed to work with the Ethics Consultant and were joined by the Senior Manager responsible for ethics (CC) and the Patient Safety Lead (ML) in developing a draft of the framework. The group started its work in January 2012 by reviewing selected literature on ethics frameworks and the role of principles and values in decision-making. Next, the group discussed the meaning of the ethical content of the Board’s statement of
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MVVs. Subsequently, the group started to generate multiple questions for each of the TBRHSC’s stated vision, mission and values, intended to determine whether a certain proposed decision or a course of action is compatible with these basic ethical statements. As the group debated the questions’ validity, clarity and applicability, some questions were eliminated, and others were combined or modified. The goal was to define 3–5 questions for each of the four declared values of TBRHSC (patients first, accountability, respect, excellence) so that the framework would be brief, but also thorough enough to assure that these selected questions reasonably assessed whether an option respected the particular value. Only one question was constructed for the mission and vision of the Centre. The group held three meetings of 1–2 hours duration. Between meetings, members communicated by email to comment on and modify various drafts of the framework. The resulting draft was presented to the whole Board of Directors and to the senior management group and further edited based on the discussion. The framework was presented to the Ethics Team of the Centre for additional input. The final version of the framework was placed in a format that provided space for users to record their responses next to questions. The framework was successfully used at two meetings of the Board of Directors to evaluate various courses of action and subsequently distributed to the Senior Management Council. An evaluation of the framework in the organization is underway.
Results The resultant framework consists of one question on the mission and vision and 21 questions on values that the Centre previously adopted. These are listed in Table 1. The leading question for each of the four values (printed in bold in the Table 1) is to be used as a first approach to decision making and for that reason these four questions are embedded on the bottom of the agenda template of the Board and Senior Management Council as well as on the briefing note template. When needed, the decision-making body is expected to consult all 21 questions. The initial reaction of users has been favourable. The Board of Directors and Senior Management Council used the template to discuss and take a position on several sensitive issues, namely, the implementation of non-smoking policy on the grounds of the institution, the process for management of patients requiring alternative level of care and the surge capacity plan. Participants felt that the use of the ethics framework lead to thorough and balanced examination of issues and to a greater satisfaction with the decision-making process.
Discussion For a number of decades it has been customary for governing bodies of health care organizations to develop and proclaim the organization’s MVVs. The word ‘‘ethics’’ may not appear in these documents, but values selected are invariably ethical values and these documents can be seen as an ethical commitment of the organizations to
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HEC Forum Table 1 Framework for Ethical Decision- Making Mission: To advance world-class Patient and Family Centred Care in an academic, research-based, acute care environment. Vision: Healthy Together
Question:
Values:
Questions:
A. Patients ARE first:
1. Does the course of action address a significant need of our patients or our community?
Respond respectfully to needs & values of patients and families
B. Accountability: Advance quality, safety and Patient and Family Centred Care & be accountable for delivering fiscally responsible services
O yes
Does the Course of Action Uphold the Hospital Mission and Vision?
O partially O no
O yes O partially O no
2. Was there a fair consultation process about the course of action, including representation of those who are disadvantaged or unable to speak for themselves?
O yes
3. Have we engaged the patients and families in dialogue, using language that they understand and encouraging open and honest expression of opinions?
O yes
4. Is the course of action guided by values of patients and families, esp. those most affected and most vulnerable?
O yes
5. Would this course of action be defensible as ‘‘putting patients first’’ under tough scrutiny in the public forum?
O yes
1. Will the course of action improve safety and reduce risks for patients or could the course of action possibly have an opposite effect?
O yes
2. Is the course of action expected to increase the quality of care?
O yes
O partially O no O partially O no O partially O no O partially O no O partially O no O partially O no
3. Does this course of action create a fiscal impact on our organization?
O yes O partially O no
4. Is there a fiscal impact compatible with other important fiscal commitments?
O yes O partially O no
5. Does the course of action represent prudent use of resources allocated wisely on the basis of fair and publicly- defensible reasons and procedures?
O yes
6. Will the course of action promote the public’s trust in our organization?
O yes
O partially O no O partially O no
C. Respect We honour the uniqueness of every individual
1. Does this course of action demonstrate due consideration for the dignity and rights of others?
O yes O partially O no
2. Was there an effective process to learn about the uniqueness of every individual? (e.g. those who are hearing impaired, those for whom English is not their first language, and those with mental illness)
O yes O partially O no
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D. Excellence We are recognized leaders in Patient and Family Centered Care through the alignment of Academics and Research with Clinical Services.
3. Is the course of action sensitive to the needs, interests, feelings and preferences of patients, which are diverse and can be influenced by a range of factors, including cultural, religious and socioeconomic backgrounds?
O yes
4. Does the course of action negatively impact on another population or result in favouritism or reverse discrimination?
O yes
5. Does the course of action provide a reasonable accommodation of individual needs and preferences of our patients? (i.e., aboriginal healing practices)
O yes
1. Will the outcome of this course of action surpass ordinary requirements or standards?
O yes
O partially O no
O partially O no O partially O no O partially O no
2. Was a reasonable evaluation of the evidence conducted and does it support this course of action?
O yes O partially O no
3. Does this course of action support ‘‘Best Practice’’; that is, the practice that has proven to be most effective in providing a specific outcome?
O yes
4. Will the course of action advance the hospital as a leader in patient and family centred care?
O yes
O partially O no O partially O no
5. Does the course of action encourage and support learning and/or research?
O yes O partially O no
their patients, clients, staff and the population. MVVs appear in annual reports, on organizations’ websites and in other formal documents; framed copies of MMVs may be placed on walls of staff rooms and corridors. However, it is uncertain to what degree the staff of the organization is familiar with these statements and how much influence they have on the operation of the organization. Researchers who examined ethics frameworks of another kind, those found in strategic policy documents, concluded that it is unclear whether these frameworks function possibly only as ‘‘aesthetic frames’’ to make policies appear ethical (Giacomini et al. 2009). Similar concerns can be raised about the frameworks of health care institutions. We did not find any publications that reported comparisons between the values incorporated in MVVs and the values that were used in the same organization to construct a framework for ethical decision-making. These two sets of values are usually created at different levels of the organizations. In Canada, MVVs are usually composed by the board of directors, while frameworks for ethical decision-making are created by ethics consultants or committees. We found only a few instances in which frameworks refer to MVVs. In one organization, the proposed framework promotes the use of ‘‘four-boxes’’ to gather facts, and then suggests that ethical analysis should be undertaken ‘‘in view of the MVVs,’’ but also ‘‘in light of established bioethical principles.’’ No further details are provided (Ethics Services at Providence Health Care 2012). Another organization created a 22-page, complex,
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multilayered ‘‘Ethics Framework’’ that contains one paragraph on the organization’s MVVs. These are proposed to be foundations for ethical decision-making, together with nine other principles and considerations (legislation; relationships, teamwork and communication; veracity and fidelity; utility; justice; confidentiality and privacy; virtues and reflective practice; respect for diversity and context) (Hamilton Health Sciences 2010). Finally, a framework that consists of eight procedural steps also lists ‘‘organizational mission/values’’ as one of the principles to be used for ranking decision alternatives (Coughlin 2002). We could find no communications or publications reporting that an institution’s MVVs were used as a sole or privileged basis of an ethical decision-making framework for the organization, as we have done. Some advantages of creating a framework using the process described here are obvious. If the ethical decision-making framework is based on the MVVs already adopted by the organization, it increases the likelihood that the organization’s MVVs will actually guide ethical decision-making. In addition, by trying to apply declared values in actual situations, the organization’s MVVs itself will be subject to scrutiny; if the statement does not fit the organization, if it contains too many internal contradictions or is incomplete, these deficiencies will become apparent. Staff could then build momentum within the organization to modify the MVVs. Another advantage of a framework based on MVVs is that such a framework will use the language and terms which are already in circulation in the organization, and this may make such framework more readily approved and used by management and staff. It may be that the importance of any decision-making framework is not even so much in the document itself, but in the process of developing it, educating the staff about it, and monitoring its use. All these activities can lead to increased staff engagement in the recognition, discussion and where possible, resolution of ethical issues in day-to-day work. We do not claim that the questions we have generated for our framework are the only or the best way to test if a certain decision option is expressing or supporting the set of values of our organizations. If the same process were carried out in another organization, even one based on the same values, entirely different questions might emerge, because the questions are likely linked to specific problems, tensions or successes that the organization has experienced. Even if several groups of board and staff members in one organization were to undertake this exercise, several sets of questions may emerge because of the personal background and experience of the individuals involved. Empirical research into the process by which frameworks are, or could be created and used would be a useful topic for future studies. A possible risk of our approach to the development of an organization’s ethical framework could materialize if the organization’s declared MVVs do not fit the organization, and the moral atmosphere of the organization is such that no one cares or feels permitted to raise the issue of their inadequacy. In this case, a decisionmaking framework based on MVVs could be unhelpful or even misleading. Another objection to our approach could be that such a simple framework trivializes the difficulty of making ethical decisions, which surely need to take into account more than simply an organization’s mission, vision and four values. In response, we suggest that the framework is an instrument to open discussion and can facilitate a
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decision but should never be considered a final, precise tool that somehow automatically generates a ‘‘correct’’ decision. Objections could be raised that our framework does not distinguish between organizational and clinical ethical decision-making. We note that some of the questions of our framework are more relevant to one or the other type of issues arising in health care institutions; however, clear distinctions between organizational and clinical ethics often cannot be made (Bean 2011), and it would be counterproductive to have two separate frameworks. It should be noted that our framework was not designed to promote any numerical evaluation of responses, averaging, scoring or creating a threshold of acceptability. We feel that a global assessment of responses to all questions, performed separately for each decision option, gives the person or a group using it a good general idea of those options that are clearly inappropriate and those that may be ethically preferable. We also see the possibility that our framework could miss some morally significant aspect of the situation or decision options, and that the final decision may not always be made only from the framework. Sometimes, in evaluating various options for action, a deeper, not immediately apparent moral commitment may emerge that points toward a decision option that the framework does not favor. For example, an organization’s MVVs and framework may strongly support a decision option that fully respects a client’s autonomy. However, when a specific client’s capacity is borderline, health care workers may feel obliged to act on their own interpretation of the client’s best interest. Even then, using the framework can be helpful, because of its ability to unearth unarticulated agendas and commitments. This may also lead the users to further research the area of concern to ensure it is ethically sound. Ideally, an ethics decision-making instrument should be evaluated to determine how it is used in the organization and how it meets the needs and expectations of users. However, we did not find in the published literature any such evaluation of frameworks for ethical decision-making created for hospitals and similar institutions. Our group has undertaken an evaluation of our framework at the Senior Management Council level with a Board evaluation to follow. Various levels of our organization will begin using the framework if the evaluation is favourable.
Conclusions If a health care institution wishes to develop a framework for ethical decisionmaking and has already adopted a MVVs, the framework could be based on this basic ethical commitment. A working party of Board and staff members may generate a set of questions to be used to decide on ethical suitability of any decision option. A framework created in this way may be simple enough to be used in a variety of health care settings and may help to make a connection between the organization’s declared MVVs and its day-to-day operation. Acknowledgments Many thanks to Loretta Delea and Wendy Lange for administrative support and to Marion Agnew for editorial assistance.
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