The recent press storm detailing ethical failures within the NHS highlights the oversimplification (to two words) and under analysis (in two words) of the ethics challenge. This blog focuses on those two words: “moral purpose”. The key question is how will this “moral purpose” result in more ethical decision-making throughout the NHS but within the context of the NHS’ reality? Calling for a moral purpose is useful if it is shorthand for calling for on-going comprehensive ethics oversight and not a one-shot tagline. For the moment, the prescription is for these two words (with a code of ethics and dismissal of leaders as the over the counter add-ons).Taking a step back, one of the key challenges with ethics is the impossibility of isolating ethics reflection from reality. The NHS does not operate as an island or in an ideal world. The ethics oversight that has been so sorely lacking must address the NHS as part of the larger British landscape in an even larger imperfect world. The NHS will never have an unlimited budget, infallible medical experts, cures for all that ails Britain, immunity from political impropriety, or perfect decision-making or execution at any level. All organizations fundamental to human life face these challenges – whether medical humanitarian aid, road safety, addiction centers, or law enforcement. Their ethics intersect with budgets, regulation, politics, human error, practical reality, patient unpredictability, pressures on results (again, often human life), and even bouts of irrationality. Effective ethics oversight of the NHS must avoid separating ethics from this context or reducing ethics to two idealistic words.
In this intertwined reality, ethics are first and foremost about quality of decision-making. This means all decisions at all levels on all matters all the time. Effective ethics oversight infiltrates all levels of decisions and organizations – not just the moral purpose guiding the decision or the senior managers who might step down. In my ethics consulting, I use a working definition of ethics: “an on-going determination of moral principles guiding conduct, taking into account all relevant information, values, and current and future impact on all stakeholders (including the public).” (See ____.) How does this play out for the NHS?
- What does “moral purpose” mean – in the London Times or in NHS hospitals? As my definition suggests, the starting point is defining “moral purpose.” Organizational moral principles and values require specificity and clarity. Would the nurses, cooks and cleaning staff understand “moral purpose” the way the board or health minister dictates? Or the way journalists use it? Surely the intent is a uniform interpretation of moral purpose. These two words left on their own are unlikely to be understood in the same way by all in light of such varied NHS roles, personal criteria, cultural backgrounds, and personal moral principles.
- How does moral purpose link to conduct? Moral purpose must be operationalized. Ethics oversight requires linking the moral purpose and underlying principles to decision-making, conduct, and evaluation. How does “moral purpose” affect the NHS’ minute by minute choices that require balancing the bad against the worse – put bluntly, often one human life versus another? Ethics live within dynamic, highly pressured operating systems. The NHS needs an ethics operations plan not a two-word declaration. Without a concrete plan and the practical mechanisms to back it up, at best “moral purpose” is a sticky media plaster likely to fall off with a change of headlines.
- How is buy-in assured? Moral principles need buy-in. How was the moral purpose declaration determined? Two words imposed from “on high” don’t work. Moral principles and their links to conduct must reflect the community, especially in a bureaucratic, reality-stressed environment like the NHS. According to recent press, these words emanate from health sector leaders not from thoughtful organization-wide ethics consideration. Presumably the pending code of ethics touts transparency. The starting point is transparency on the process of defining the NHS’ moral purpose and developing and implementing the code.
- What is the information required to ensure proper ethics oversight? Moral principles require information for correct application. The aforementioned plan must assure that all decisions are taken and implemented with adequate information. Processes must be in place to move information to the decision-makers and action-takers in a timely, appropriate manner.
- What is the impact on all stakeholders (including the public at large)? One of the most common ethics crises stems from failure to consider broadly enough the ethical impact on all stakeholders (including the public at large). NHS leaders should map much more rigorously breadth of impact far beyond moral purpose or even the patients. On the other end of the spectrum, the individual members of the NHS team at all levels (most of whom are likely extremely competent, hard-working, and well-intentioned) should ask two questions. First, if they were the patient, how would they react to the decision or conduct? Second, if they look back on their contribution – whether at that moment, that day, that month, or that career – what do they want their own legacy to be to all stakeholders?
- How does the “moral purpose” affect leaders? Calling for a leader’s resignation may or may not be a good idea. In the wake of ethics crises, leadership change may be important for managerial, symbolic, or even enforcement reasons. Alternatively, they may be unfairly punitive and detrimental to the organization. Either way, leadership change does not solve the underlying ethical problem. Heads are attached to organizational bodies. Neither the dismissal of a former head nor the hiring of a new head will alone cure what ails the rest of the body. Either way, the question must point upward and not only downward. Where were the relevant governing bodies? Where were the reporting and oversight systems that should have prevented the now criticized complacency– or at the very least caught them at every annual CEO review and through other internal review processes? CEOs may be responsible for their own conduct and conduct within the organization, but boards are responsible for the CEO…and ethics oversight.
- Two words can lead to complacency. Often regulators, organizational governing bodies, and even the media stop at buzz words. Moral purpose for now is just two words. Without the above implementation, it is also itself an ethical hazard as buzz words often lead to complacency. A dangling call for moral purpose could do far more harm than good by erroneously conveying internally and externally a sense of quick-fix resolution to an immensely complex illness.
- Relationship to the Code of Ethics. I have not yet been able to see the code of ethics mentioned in recent press. However, the same analysis applies to codes as to two-word remedies. A code is only as effective as its implementation – in real time in the real world within a real budget. Codes must reflect buy-in; offer clarity of requirements and consequences; link to conduct; and consider implications on all stakeholders (including the general public).
In sum, left alone (or even accompanied by a code and the dismissal of a leader), a moral purpose declaration can itself raise an ethical issue. The remedy for the NHS is on-going, extensive ethics oversight not two words.
Copyright 2013 Susan Liautaud & Associates Limited. All rights reserved.