- Ethical decision-making
Decisions that take into account values, morals and norms
New managers in the healthcare system will be faced with multiple and sometimes competing frameworks that guide practice. These may include managerial ethical frameworks, clinical decision-making frameworks and in some cases religious frameworks. All of these may come into play around single or multiple issues, increasing the complexity in finding an acceptable ethical solution satisfying all of the competing values, including those of the patient.
Health managers face many challenges in today’s work environment, which is characterised by rapid changes, globalisation, tough competition and higher demands for socially responsible healthcare provision. In such a complex and uncertain milieu, managers must make decisions affecting not only their organisation, their personal career, their patients and their families, but also the wider community. Achieving an understanding of how those decisions are made is vital.
Research has shown that the likelihood of making unethical decisions in the workplace is relatively high. In Australia and New Zealand, results from KPMG’s (2004, 2013) forensic fraud surveys in 2004 and 2012 indicate that unethical practice at both individual and organisation levels is real and alarming (see Table 3.1).
| 2004 | 2012 |
|---|---|
| 33% of employees had witnessed unethical or improper conduct at work during the previous two years. | 43% of the respondent firms experienced fraud. |
| 22% attributed unethical or improper conduct at work to senior management’s lack of commitment to the organisational ethical code. | 30% of the respondent firms detected less than 40% of frauds in their organisation. |
| 18% believed a poor ethical culture contributed to unethical behaviours. | 47% of the major frauds occurred due to deficient internal controls. |
Even if these results reflect the actions of only a few bad managers, those unethical behaviours were widely visible to others and are likely to have influenced decision-making within the organisational culture that allowed them to exist. These statistics present a challenge to those wanting to promote virtuous or ethical management behaviour in organisations.
Despite best efforts to address the problem by introducing so-called ethics regimes into organisational culture (Preston, 1994), unethical practice can be as resistant to bureaucratisation as it is to legislation. While good regulations and sound organisational practices are important, ethics goes beyond good rules and good practices; it involves the ability to make value-based judgements appropriate to personal and professional identities and situational contexts, both regular and irregular.
Creating and sustaining procedural uniformity when dealing with ethical issues in organisations is a near impossible task. Ethical decision-making at the managerial level remains highly individualised work even when it necessitates collaboration, as the manager is often the one responsible for getting people together and facilitating groups to discuss problems, as well as monitoring and evaluating outcomes. In completing their tasks, managers are subjected to a wide range of influences; they can react differently to diverse situations, and, even if they are not guided by commitments to contrasting ethical principles, they may still prioritise them in varying ways.
A preference for a particular ethical approach is only one of the factors that can influence a decision-maker, and all of the individual differences that arise from the variable influences of these factors can increase complexity and uncertainty in an organisation, especially when it comes to predicting behaviour. Recently, organisations have introduced codes of ethics and codes of conduct as tools to minimise the likelihood of staff engaging in unethical behaviours. Nevertheless, as Guy (1990, pp. 25–26) argues, ‘these cannot replace ethical decision making; they can only supplement what is within the individual, which is his or her own set of principles applied to each decision made’. The mere introduction of a code of ethics without taking into consideration these individual differences, then, could be detrimental for the organisation. Instead of achieving a higher degree of consistency across the organisation when facing particular ethical situations, codes could create more conflict between staff, as they will inevitably differ in their interpretations of the codes and the situations to which they are to be applied. The factors influencing these differing responses are embedded in each individual manager and are open to investigation.
Influential factors
Individual responses in the decision-making process are the results of numerous factors that have contributed to the creation of the personality of the person making the decision, and more specifically to their particular predispositions (or heuristics). It is not possible, for example, to separate nationality from the individual. But then, an individual from a particular ethnic background could act differently from another individual from the same ethnic background because of other factors, in addition to cultural norms and values that have contributed to the development of the two individuals’ characters.
- Heuristics
Individual procedures, guidelines or rules of thumb developed to assist people in solving complex problems (Bazerman, 2005)
Bazerman (2005) defines heuristics as individual procedures, guidelines or rules of thumbs developed to assist people in solving complex problems. Skitmore, Stradling and Touhy (1989) additionally inform us that decision-makers use heuristics as shortcuts instead of carrying out detailed analyses of problems. As a result, when solving a problem, they tend to rely upon those principles and constructs that are embedded in them, rather than engaging in a totally new decision-making process. The various factors that contribute to people’s predispositions and influence their decision-making are discussed in the sections below.
Ethical factors
The first group of factors that affect individuals’ ability to make decisions can be described as ethical or moral – that is, beliefs about right and wrong. Morality can be taken to mean ‘moral judgments, standards and rules of conduct’ (Ferrell, Fraedrich & Ferrell, 2005, p. 5) or ‘the principles, norms, and standards of conduct governing an individual or group’ (Trevino & Nelson, 2007, p. 13).
- Morality
The standards, principles and rules that govern an individual’s or a group’s conduct
Generally, people hold different sets of values, morals and norms; however, they all involve a claim that one ought to act in a certain way. Due to this normative propensity, ethics and morality tend to be constructed of shared understandings which are responsive to the demands of particular contexts. Being socially and historically embedded, the quest for shared understandings has led to the creation of various schools of moral philosophies. In everyday decision-making, we knowingly and unknowingly tend to draw on these philosophies.
Four major schools of moral philosophy have been used to profile the expression of morality in ethical decision-making: egoism, utilitarianism, virtue ethics and deontology. These cover a spectrum of ethical styles, from a focus on consequences (utilitarianism and egoism), through a focus on the moral traits within people developed from habit and education over time (virtue ethics), to a focus on universal principles and duties which ought to be applied in all like circumstances (deontology) (Ferrell, Fraedrich & Ferrell, 2008; Trevino & Nelson, 2007).
- Egoism
A doctrine that maximises the greatest good or benefit for the individual
- Utilitarianism
A doctrine that maximises the greatest good for the greatest number of people
- Virtue ethics
A system that focuses on the embodiment of virtues in the individual
- Deontology
An ethical theory that applies universal principles and duties in all similar circumstances
The main difference between utilitarian and egoistic philosophies is one of scope. Utilitarians are concerned with creating the greatest good for the greatest number, while egoists commit to maximising the good for themselves alone. A similar difference of scope could be said to apply to deontology and virtue ethics. Deontologists focus on universal rights and duties, while virtue ethicists focus on the embodiment of virtues in the individual. These traits are acquired through learning and habits.
In the past, the virtue ethics approach has been most closely aligned with professional life when practitioners are trained in groups under apprentice-like conditions (such as nurses and doctors) but go on to practise mainly as individuals. In such a setting, codes of ethics expressing universal principles are also important, but until recently greater emphasis has been placed on the character and integrity of the practitioner and their ability to interpret the application of those rules independently.
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