The basic process of strategic management involves formulating a strategy, implementing the strategy, and then continuing evaluation and control (Hunger & Wheelen, 2007; Preble, 1997). The first step, strategy formulation, is the most important and most involved because it requires gathering information on current internal strengths and weaknesses, including performance, objectives and culture, as well as identifying external influences, threats and opportunities. This SWOT (Hunger & Wheelen, 2007; Preble, 1997) analysis helps the organization to identify where they are currently within the industry, and pushes the development of strategies to achieve goals of where the organization wants to be within the industry (Ginter, 2004). The next step, the strategy implementation, is the action step that addresses the actual process of making the strategy a reality. This step formulates and employs the policies and procedures, programs and necessary budgeting in order to fulfill the formulated strategy (Hunger & Wheelen, 2007). The final step of the strategic management process is the continued evaluation and control of the implemented strategy (Hunger & Wheelen, 2007; Preble, 1997) Since the internal and external environments are likely to change with sociopolitical and economic influences, it is important to maintain a flexible strategy that is regularly reevaluated in order to ensure that it maintains its efficacy within the market and organization.

An example of strategic management within the healthcare industry would be as follows: a healthcare organization has the mission to provide the best patient care possible to their local community. The hospital completes a SWOT analysis, identifying that they have outstanding clinical and customer service (strengths), however they have a lengthy wait time in the emergency department due to overutilization secondary to long delays in accessing primary care providers (Arnst, 2007); this weakness causes financial hardship on the organization because of the higher operating costs and reduced control. On analyzing the external opportunities, the hospital recognizes a community need for an after-hours clinic that would allow for better patient service as well as reduced emergency department utilization. Threats to the organization include the current sociopolitical environment and the instability of the healthcare insurance base within the patient population. Upon completion of the SWOT analysis, the hospital reviews their mission to serve patients by providing the best care possible. This in turn leads them to conclude that they have various alternatives, including making no change, implementing an after-hours clinic, or expanding the emergency department. After considering the resources and costs involved, as well as the internal and external impact, the hospital decides that the best alternative is to provide an after-hours clinic. Next, the technical details of budgeting, developing policies and procedures, and establishing a community recognized program. Finally, the hospital must continue to reevaluate and control the implementation of the strategy, continuously evaluating whether the alternative is actually beneficial to the organization and the community and helping to provide a competitive edge within the healthcare industry.

References

Arnst, C. (2007). The doctor will see you in three months. Retrieved 6 February 2010 from http://www.businessweek.com/magazine/content/07_28/b4042072.htm.

Fottler, M., Ford, R., & Heaton, C. (2010). Achieving service excellence: strategies for healthcare (2^nd ed.). Chicago, IL: Health Administration Press.

Ginter, P. (2004). Strategic management. Retrieved 13 February 2010 from http://www.credoreference.com/entry/sageeohcm/strategic_management.

Hunger, J.D. & Wheelen, T. (2007). Essentials of strategic management; (4^th ed). Upper Saddle River, New Jersey. Prentice Hall.

Preble, J. (1997). INTEGRATING THE CRISIS MANAGEMENT PERSPECTIVE INTO THE STRATEGIC MANAGEMENT PROCESS. Journal of Management Studies, 34(5), 769-791. Retrieved from Business Source Premier database.

“E-commerce changes the characteristics and rules of business competition through electronic flows of information and money” (Shi & Wright, 2003, p. 1). The technology available reshapes the information available to consumers, allowing for greater exchanges of information between people, businesses and consumer organizations (Kato, 2010). Instead of being limited to physical boundaries, competitors may now advertise across geographic locations, shipping to customers worldwide. Businesses have now destroyed the conventional means of competition through creative use of technology (McKenney, Copeland & Mason, 1995). The advances in technology have changed the target market and increased competition in areas that may have previously been dominated by a single firm. IT designs have become competitive necessities in many industries (McKenney et al., 1995). “Firms that do not keep abreast of the technology become stuck in an application that is approaching obsolescence, and their competence begins to erode” (McKenney, et al., 1995, pg x).

Another way that technology is changing the competitive business landscape is through increasing efficiency and reducing costs (Hunger & Wheelen, 2007). Information systems can eliminate employee decision processes, saving time and allowing personnel to work in other areas. The healthcare industry has been significantly impacted by changes and advances in technology. Electronic medical records have changed the availability and access of personal health information. Advanced information systems may monitor vital signs on critical patients over wireless networks; this technology not only improves care and allows for specialization of care but also supports cost-efficiency and competitiveness within the healthcare industry (Gao, Greenspan, Welsh, Juang & Alm, 2005). Similar to other corporate businesses, products and services may be compared online through private and public ratings, consumer websites and government (Austin, 2005). Overall, technology has had a significant impact on the healthcare industry and the competitive landscape of healthcare delivery.

References

Austin, K. (2005). IMPROVING CARE THROUGH IT. AHA News, 41(8), 7. Retrieved from Business Source Premier database.

Barr, J. (2008). Secure telecommuting policies. Retrieved 2 March 2010 from Faulkner database: http://wf2dnvr1.webfeat.org/.

Gao, T., Greenspan, D., Welsh, M., Juang, R., & Alm, A. (2005). Vital signs monitoring and patient tracking over a wireless network. Retrieved 2 March 2010 from http://www.eecs.harvard.edu/~mdw/papers/monitoring-embs05.pdf.

Hornung, S., Rousseau, D., & Glaser, J. (2008). Creating flexible work arrangements through idiosyncratic deals. Journal of Applied Psychology, 93(3), 655-664. doi:10.1037/0021-9010.93.3.655.

Hunger, J.D. & Wheelen, T. (2007). Essentials of strategic management; (4^th ed). Upper Saddle River, New Jersey. Prentice Hall.

Kato, S. (2010). How information technology is changing business trends. Retrieved 2 March 2010 from http://www.nli-research.co.jp/english/socioeconomics/1997/li9706.html.

McKenny, J., Copeland, D., & Mason, R. (1995). Waves of change: business evolution through information technology. Cambridge, Massachusetts. Harvard Business School Press.

Reed Business Information. (2004). Six technologies are projected to impact small business competitiveness in 2005. MSI, 22(12), 26. Retrieved from Associates Programs Source Plus database.

Shi, X., & Wright, P. (2003). E-COMMERCIALIZING BUSINESS OPERATIONS. Communications of the ACM, 46(2), 83. Retrieved from Associates Programs Source Plus database.

Healthcare employees must be competent in their role, whether that role involves direct patient contact or not. All necessary certifications and regulations must be met, and the necessary education must be obtained in order to be competent (BLS, 2009). Also, healthcare workers have an obligation to perform at higher levels due to the nature of their work; they must have the knowledge, skills and abilities to perform their duties in difficult and stressful situations. Services must be provided in a professional manner, and must show good decision making skills and prioritizing (Fottler, et al., 2010). In healthcare workers, a combination of customer-service skills and technical/clinical skills are necessary.

Healthcare and other service organizations are related, and, while the technical competencies are different, the social and personal commitment to excellence is the same in the industries (Fottler, et al., 2010). These are essential components of staff quality because the staff’s competency directly affects the success of the organization.

References

Bureau of Labor Statistics (BLS). (2009). Customer service representatives. Retrieved 21 January 2010 from http://www.bls.gov/oco/ocos280.htm.

Bureau of Labor Statistics (BLS). (2009).Physicians and surgeons. Retrieved 21 January 2010 from  http://www.bls.gov/oco/ocos074.htm.

Fottler, M., Ford, R., & Heaton, C. (2010). Achieving service excellence: strategies for healthcare (2^nd ed.). Chicago, IL: Health Administration Press.

The first case of HIV/AIDS in the United States was identified in 1981; however a blood sample taken in 1959 confirms the existence of the disease at that time (History of AIDS, 2005; Gorman, 1998; Coughlin & Beauchamp, 1996). Initially, significant negative stigma hindered the public health processes that may have helped to identify and slow the progression of the disease within the society. HIV was viewed as a gay man’s disease, and diagnosis with the virus could have resulted in residential eviction, professional termination, social isolation, and other discriminatory practices (Beauchamp & Steinbock, 1999). The development of testing for HIV had additional negative connotations as some intended the results to identify homosexuals in order to fire them (Beauchamp & Steinbock, 1999). Due to the severe public reaction, public health information was gathered at a cost of extreme confidentiality; identifying the disease but not the individual carrying it. In this manner, the containment of the disease was slowed and transmission of the disease was not adequately countered.

In the after effects of the civil rights protections, public health means have been significantly hampered. As of 1999, testing was voluntary under most situations, and routine testing was prohibited (Beauchamp & Steinbock, 1999). Since people may be asymptomatic for extended periods of time while carrying HIV/AIDS, they are likely to continue engaging in risky behavior that may expose others within the population. “The incubation period between infection with HIV and a diagnosis of AIDS is often longer than ten years” (Beauchamp & Steinbock, 1999, pg. 215). One would conclude that HIV testing at earlier stages would allow patients to receive beneficial treatments earlier, as well as to practice safer behaviors that would reduce the risk of exposing others to the virus. With an asymptomatic incubation period of approximately ten years, adequate testing could potentially affect entire generations, reducing actions that could have otherwise been prevented by HIV-status awareness. Within the realm of public health, many diseases may be tested for without explicit patient permissions; however, due to the limitations and exceptions placed on HIV/AIDS because of the early stigma, the current population suffers without proper disease prevention and detection.

According to the CIA (2009), 1.2 million Americans are living with HIV/AIDS, with an estimated 33 million infected individuals worldwide. Approximately 40,000 new cases of HIV/AIDS are identified each year (Branson, Handsfield, Lampe, Janssen, Taylor, Lyss, Clark, 2006). As of 2002, 24,844 healthcare personnel were reported to have AIDS (CDC, 2003).

Given that over one million Americans have HIV/AIDS and an approximate 25,000 healthcare workers have been infected with the virus (CDC, 2003), one would naturally consider routine screening of the population, especially those at higher risk for exposure and transmission of the virus. Early detection may lead to a reduction of risk-exposure behavior, and early treatment may improve the outcomes and quality of life of a HIV/AIDS positive patient (CDC, 2003; Branson, et. al., 2006).

In 2006, the CDC updated their guidelines for HIV/AIDS detection: the current recommendations include routine testing for HIV/AIDS as part of the general medical examination for all individuals aged 13 to 64; as well as discontinuing written consent for testing while allowing for an informed opt-out of testing (Branson, et. al., 2006, Gostin, 2008). As the public has gained knowledge into the disease and the populations at risk, there is more understanding of lifestyle and exposure risks; and a person is less likely to be discriminated against due to their HIV/AIDS status.

Considering the obvious benefits of HIV screening (CDC, 2003; Branson, et. al., 2006), it is important to consider the routine testing of the general population yearly or relative to their risk level. “Screening is the systematic application of a medical test to a defined population with the objective of identifying persons with infectious diseases” (Gostin, 2002, pg. 394). Screening that is based on minority or sexual orientation may be considered discriminatory; however screening based on risk-exposure within the professional context of healthcare is an avenue of protecting the patient and within the burden of obligation secondary to the healthcare workers’ right to practice.

There are valid arguments against mandatory screening of healthcare providers, including the provider’s own privacy and right to freedom against discrimination (Fremgen, 2009).  However, one would argue that the benefits of protecting patients from risky procedures performed by HIV positive physicians, as well as protecting immunocompromised providers from secondary infections and diseases would outweigh the right to privacy for a healthcare provider. In the event that the patient was infected, having not been informed of the provider’s viral status, the provider may be found liable of misconduct or even malpractice. The Federation of State Medical Boards states that a healthcare provider not knowing their HIV-status would be professional misconduct (Fremgen, 2009). In lieu of this statement, one would logically conclude that healthcare workers, particularly those working in high-risk areas and may expose patients to HIV-positive bodily fluids, should be required to be tested for HIV/AIDS.

Any healthcare organization has vicarious liability for the actions of their employees (Rodriguez, 2009); by routinely testing employees for infectious diseases such as TB and HIV/AIDS, a hospital may be able to reduce the liability carried by providers performing risky procedures without knowing their viral status. The providers’ right to personal privacy only extends as far as their professional obligation to protect their patients: their ethical and moral obligation to respect the autonomy of the patient and to non-malfeasance supersedes their personal privacy.

In the same vein as TB testing for healthcare workers, HIV/AIDS testing should be required for all healthcare workers relative to the risk of patient exposure. For example, those providers who are at high risk of exchanging or exposing others to bodily fluids should be tested at a higher frequency than ancillary staff with limited or no direct-contact with patients. Because of the vulnerable and delicate nature of the provider-patient relationship, it is important that healthcare workers, the healthcare organizations employing them, and the applicable patients, are made aware of the potential risk involved with a provider’s HIV/AIDS status.

Providers that test positive should not be discriminated against; however, they must also maintain the legal, moral, and ethical standards of their profession. Providers who are known to have HIV/AIDS should behave in a manner that limits others’ exposures. This includes regular protection against the exchange of bodily fluids, including gloves and masks as indicated by the CDC and standards of the profession. Additional precautions may be necessary if the context of the job design lends to using sharp objects, such as phlebotomy, surgery, emergency departments or obstetrics/gynecology (Fremgen, 2009).

While healthcare workers may have a low probability of infecting their patients (Fremgen, 2009; CDC, 2003), one would still conclude that a healthcare professional has a moral and ethical obligation to do no harm and to protect the patient’s autonomy by disclosing all necessary information to make an informed decision. In addressing the medical code of ethics, a physician is obligated to address the principles of respect for persons, beneficence, non-malfeasance and justice (Rodriguez, 2009; Fremgen, 2009).

Particularly within the principle of respect for persons, it is important for physicians to be truthful so that a patient may make his or her own decision. The healthcare provider has a duty to disclose information that a reasonable person would need to make an informed decision. If an invasive or risky procedure is being discussed, than the provider’s HIV/AIDS status would be necessary information in order for the patient to make an appropriate healthcare decision. Healthcare workers that are HIV/AIDS positive should not perform invasive procedures that could place their patient at risk (Fremgen, 2009, CDC, 2003).  In either case, if the provider is positive, than they have an ethical obligation to disclose this information to the patient prior to the procedure, or should decline to do the procedure so as not to break fidelity with the patient.

A second principle of the medical code of ethics is non-malfeasance (Rodriguez, 2009; Fremgen, 2009).  Following this principle, a physician may not do harm to a patient. By inadvertently exposing a patient to the risk of HIV/AIDS contraction, even if the probability is low, is unacceptable because it generates unnecessary risk and potential harm.

After careful consideration of the aforementioned data, one would conclude that the public good of provider screening for HIV/AIDS is a greater need than the individual provider’s privacy. “Unless the medical profession is occasionally willing to put public interests before individual patient (and physician) interests, the social trust will falter” (Wynia, Kurlander & Green, 2006). As this quotation demonstrates, without some sacrifice on the side of the healthcare workers’ privacy, the trust in the healthcare system will fail. Without appropriate trust in the healthcare professionals and system in general, both public and individual health will suffer. In order to maintain the dignity of the profession, healthcare providers should be required to be screened and precautions should be taken to protect the interests of positive healthcare workers and their patients.

References

Beauchamp, D. & Steinbock, B. (Eds.). (1999). New ethics for the public’s health. New York, NY: Oxford University Press.

Branson, B., Handsfield, H., Lampe, M., Janssen, R., Taylor, A., Lyss, S., Clark, J. (2006). Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings. Retrieved 6 December 2009 from http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.

C.I.A. (2009). The world factbook. Retrieved 6 December 2009 from https://www.cia.gov/library/publications/the-world-factbook/fields/2156.html?countryName=&countryCode=&regionCode=T

Centers for Disease Control and Prevention (CDC). (2003). Surveillance of healthcare personnel with HIV/AIDS, as of December 2002. Retrieved 6 December 2009 from http://www.cdc.gov/ncidod/dhqp/bp_hiv_hp_with.html.

Coughlin, S. & Beauchamp, T. (Eds). (1996). Ethics and epidemiology. New York, NY: Oxford Press.

Fremgen, B. (2009). Medical law and ethics (3^rd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Gorman, C. (1998). When did AIDS begin? Retrieved 6 December 2009 from http://www.time.com/time/magazine/article/0,9171,987824,00.html.

Gostin, L. (Ed). (2002.) Public health law and ethics: a reader. Berkley, CA: University of California Press, Ltd.

Gostin, L. (2008). Public health law: power, duty, restraint (2^nd Ed.). Berkley, CA: University of California Press, Ltd.

History of AIDS. (2005). The history of AIDS. Retrieved 6 December 2009 from http://fohn.net/history-of-aids/.

Rodriguez, R., Ph.D. (2009, November 19). Chat posting. Retrieved from AIU Online Virtual Campus. Chat 1 week 2. The ethical and legal aspects of healthcare: HCM410-0904B-02 website.

Wynia, M., Kurlander, J., Green, S. (2006). Physician professionalism and preparing for epidemics: challenges and opportunities. In Balint, J., Philpott, S., Baker, R., & Strosberg, M., (Eds.), Advances in bioethics (Vol. 9). Oxford, UK: Elsevier.

Within the healthcare system, it is important for healthcare professionals to maintain ethical standards, including those that govern respect for persons, a primary component of which is autonomy, and beneficence.

According to R.G. Rodriguez, Ph.D. (2009), autonomy is an element within the professional code of healthcare ethics that allows for a patient to govern themselves in the event that they are rational, competent, conscious and not coerced. This definition is significant because it provides indications both for the patient’s autonomy as well as situations where the requirements for autonomy have not been met and autonomy should therefore not be fully granted. Spicer (2005) qualifies autonomy by adding that patients must be informed in order to make an appropriate decision; must have the capacity to decide; and must be free from coercion. These definitions differ slightly in the emphasis of information required to be autonomous; however, capacity as defined by Spicer (2005) encompasses rationality, competency and consciousness. In effect, both definitions are mutually supportive and establish complementary guidelines in determining autonomy.

The definition offered by Fremgen (2009) is limited as it describes autonomy as “independence for their beliefs” (pg. 176). The definition provided fails because it addresses only religious considerations, as well as a person’s right to decision-making based solely on competence: “As long as a person is competent, he or she has the right to make his or her own decision” (pg. 176). This does not address matters of relevance involved with determining autonomy, including consciousness or freedom from coercion. “Bioethical and legal issues arise when a person is called upon to make this decision, based upon his or her own religious beliefs, for another person such as a child or an elderly or incompetent adult” (Fremgen, 2009, pg. 176). The assumption that religious considerations are the main contributing factor for dilemmas of autonomy is myopic and impractical as many social, cultural, familial, personal and financial components may contribute to a person’s decision making with regards to healthcare treatments and options. The aforementioned definition given by Fremgen also implies that people without religious considerations would not have ethical dilemmas when making healthcare decisions for themselves or others. However, one would conclude that the complexity of the human condition is still relevant even in the absence of religious belief. Therefore, in consideration of the inefficiency and of the definition provided by Fremgen, the definitions given by Rodriguez and Spicer will be used to analyze the following dilemmas.

Within the ethical guidelines of the healthcare profession, therapeutic privilege offers an option for nondisclosure under certain guidelines. “Physicians may withhold information about a patient’s diagnosis or treatment when disclosing it would pose a serious psychological threat, so serious a threat as to be medically contraindicated” (Wynia, 2004, p. 14). Following the guideline of therapeutic privilege, the provider may not disclose information simply because the information would cause the patient to choose a different course of action, but only in the event that the information would cause significant unnecessary harm if disclosed and is therefore determined to be medically contraindicated (Wynia, 2004). In this way, providers partially disregard the first ethical principle, selectively disclosing information and therefore not being fully truthful and allowing for the necessary information for complete autonomy, in lieu of the second and third principles, beneficence and non-malfeasance. However, beneficence is not sufficient; the judgment must be subjective to preventing actual harm.

The second principle within healthcare ethics is beneficence (Fremgen, 2009; Rodriguez, 2009; Gauthier, 2005). Beneficence means to “act with charity and kindness” (Rodriguez, 2009); it means to use one’s skills and professional authority to care for, comfort, and if possible, cure a patient. Beneficence implies that one will fairly and justly provide services with the intention of another’s improving the patient’s wellbeing. Rodriguez’s definition is valid because it indicates the primary values of beneficence.

When deciding ethical dilemmas, it is important to not only consider the ethical obligations; respecting a person and acting with beneficence, but it is also necessary to consider the legal implications of actions within the context of the healthcare setting. The following scenarios are presented with both ethical and legal considerations:

In the intensive care unit, you are working on a patient in a very unstable state. The woman and her children (who were all killed) had been in an accident. It is clear that further emotional trauma would be disastrous to the patient and may cause her death. In a lucid moment, she looks at you and asks, “How are my children?” Is this an instance when therapeutic privilege seems reasonable? Whether you decide yes or no to the therapeutic privilege question, write a sentence that you think would be the most appropriate answer for the patient.

The primary principle of healthcare ethics being respect for persons, it is important to reflect on the components of respect, mainly: autonomy, truthfulness, confidentiality and fidelity (Rodriguez, 2009). It is necessary to carefully consider the provider’s responsibility to the patient as well as the ethical duty expected by the profession. Beyond justice, the provider has a duty to respect the person, therefore allowing for autonomy as well as being truthful; beneficence, acting in a way that lends comfort, care and possible cure to the patient; and non-malfeasance, meaning that there is no harm caused.

The above mentioned scenario offers an ethical dilemma that may appear to be conflicting. It is the provider’s duty to be truthful, but also to cause no harm. In the event that the provider is truthful, harm, even death, is possible.

If the provider tells the patient that her children are dead, given the current situation, the patient may die due to the additional emotional trauma. In this manner, by telling the patient that the children have died, the provider would be causing harm; risking the patient’s death due to this additional emotional trauma would be medically contraindicated.

However, if the provider does not inform the patient of the news, then the provider is not being fully truthful and respectful of the patient. Under absolutely no circumstances should the provider lie to the patient; saying that the children are fine or any other statement simply to offer comfort. Such a lie would constitute a breach of ethical standards as it is not truthful and may cause greater long-term damage when the woman learns of their death. Lying to the patient is inadvisable and may lead to civil litigation since it would be outside of the professional ethical norms.

Under the guidelines of therapeutic privilege, a provider may not disclose information if such knowledge is dangerous, causing such significant emotional trauma as to be medically contraindicated. In this scenario, one may consider the immediate disclosure to be a matter of therapeutic privilege because the emotional trauma resulting from the information would cause significant emotional trauma possibly resulting in death. Given the likelihood of significant danger at the current time, the provider should not answer the question, but also not offer any false hope or lies. Additionally, autonomy is contingent on rationality; in the patient’s current condition of shock and significant physical trauma, she does not qualify for complete autonomy.

One appropriate response may be to redirect the patient’s focus to her own injuries and treatment, for example: “Ms. Doe, we are doing everything possible to help you right now. We need to ask you some questions about your medical history.” As the patient is not consistently lucid, this redirection would offer additional time to stabilize her condition before adding the additional emotional burden of her children’s death.

You are working late and you enter the patient’s room to find that she has climbed out on the window ledge. She appears to be crying and tells you to leave her alone.

In the abovementioned scenario, the woman on the ledge offers another ethical consideration, contrasting the autonomy of the patient’s wishes to be left alone against the provider’s responsibility for offering care. The patient exhibits clear signs of lacking the necessary components of autonomy. Her actions are clearly not rational and arguably not competent as they are likely indications of mental illness, risk of self harm or even suicide. In this matter, the clear decision is to not fulfill her wishes to be left alone. However, staying in the room or climbing out on the ledge is not a sufficient answer to this situation. This situation needs immediate response: security and police/EMS services need to be notified. Any and all possible means to prevent harm need to be taken.

Beyond the ethical considerations, it is necessary to consider the legal impact of inaction. Had the provider observed the patient’s wishes, he or she would have been liable for any harm that came to the patient (Jenner & Welch, 2001). When a patient is under professional care, it is important for the provider to protect them from harm, even if the harm is caused by themselves as in the case of psychiatric disorders. If the provider fails to reasonably safeguard against actions of self-harm or suicide, he or she will likely be civilly liable for malpractice and negligence (Jenner & Welch, 2001).

Your elderly patient hates to have the bed rails up and tells you to leave them down.

Ethically, this scenario does not offer enough information to conclude if there is a legitimate dilemma: whether or not the patient is autonomous is unclear. The indication of age does not necessarily indicate any potential harm. There is no mention as to whether there are physician orders regarding the matter of the bed rails. The setting of the situation is unclear. More information needs to be obtained before any actual ethical determinations may be made.

However, while this scenario could offer an ethical dilemma given additional information, the more significant consideration is that of the legality of the action. Bed rails qualify as restraints; restraints must be used under the order and direction of a physician (Greenwich Hospital, 2005). Restraints are used only when absolutely necessary; to use them in any other fashion or without proper indications or medical direction could constitute unlawful confinement and may open the provider and healthcare site up to civil or criminal ramifications.

Considering all aspects of a dilemma is important, however it is necessary to consider not only the ethical factors but also the legal responsibilities within the healthcare setting.

References

Fremgen, B. (2009). Medical law and ethics (3^rd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Gauthier, CC, PhD. (2005). The virtue of moral responsibility and the obligations of patients. Retrieved 21 November 2009 from  http://wf2dnvr6.webfeat.org/qxkBN12932/url= http://content.ebscohost.com/pdf9/pdf/2005/MPS/01Apr05/16999952.pdf?T=P&P=AN&K=16999952&S=R&D=aph&EbscoContent=dGJyMNHX8kSeqK84zOX0OLCmrlGep7RSsqq4TbeWxWXS&ContentCustomer=dGJyMPGvtEyvrbVLuePfgeyx44Hy7fEA.

Greenwich Hospital. (2005). Restraint/bed rail entrapment information guide. Retrieved 21 November 2009 from http://www.greenhosp.org/pe_pdf/genmed_restraint.pdf.

Jenner, R. & Welch, B. (2001). Suicide watch: liability for negligent psychiatric care. Retrieved 21 November 2009 from http://www.medlawlegalteam.com/article_jenner_suicide_watch.html.

Rodriguez, R., Ph.D. (2009, November 19). Chat posting. Retrieved from AIU Online Virtual Campus. Chat 1 week 2. The ethical and legal aspects of healthcare: HCM410-0904B-02 website.

Spicer, J. (2005). Consent autonomy and the new practice nurse. Retrieved 21 November 2009 from http://wf2dnvr6.webfeat.org/qxkBN12924/url=http://web.ebscohost.com/ehost/ detail?vid=2&hid=11&sid=8ddc3e69-4ea1-4d2c-b570-228fdecf7b81@ sessionmgr110&bdata=JmxvZ2lucGFnZT1Mb2dpbi5hc3Amc2l0ZT1laG9zdC1saXZl#db=buh&AN=18776068.

You are a paramedic arriving at an emergency scene. A group of scouts has entered a cave that is now filling with water. They were led into the cave by a rather large scoutmaster. Unfortunately, while leading them out of the cave, the scoutmaster somehow managed to get stuck in a narrow opening with only his head and shoulders protruding out. With his upper torso stuck outside the cave, it appears the scoutmaster will survive, but all the boys below will drown if they cannot escape.

After you have checked all possible escape routes and have attempted to extricate the scoutmaster, it becomes clear that the only way to save the boys is to sacrifice the scoutmaster, so he can be removed. This is, unfortunately, not the Winnie the Pooh story where Rabbit has the option of waiting until Pooh loses weight. What is the correct action for this case?

Duty-oriented reasoning, otherwise known as deontology, deals with Immanuel Kant’s influential moral theory regarding what a person is obligated to do (Rosenstand, 2003). The reasoning behind deontology is the intention, and is based on universal principles that guide actions (Fremgen, 2009; Rosenstand, 2003). Duty-oriented reasoning concludes that the consequences of the action are not as important as the principle moral law that dictates the action; that the presence of one’s duty is the determining factor as to an action’s morality (Kant, 1785). For example, a person has a moral obligation to be honest, even if that honesty has negative outcomes. To lie, even to save one’s life, would be morally objectionable because there is a duty to be honest.

As applied to the scenario above, it is important to determine the moral obligation. As a paramedic, the implied duties and obligations are to aid those in need. The primary duty is balanced by both parties in the above scenario and does not further the decision process. A second obligation is a sociopolitical obligation to protect the most vulnerable of society.

Given the exigency of the situation, it is reasonable to prioritize. In this scenario, the greater duty would be to protect the innocent and vulnerable: to save the lives of the children. Children are considered to be some of the most vulnerable members of society; therefore assisting them holds a higher obligation in order to fulfill the duty. While this necessitates the sacrifice of the scoutmaster, the greater duty is the protection of the most vulnerable members of society. By following the moral law of protecting the innocent, the sacrifice of the scoutmaster would be a morally sound action given the circumstances.

Consequence-oriented reasoning, or consequentialism, uses a cost/benefit analysis to benefit as many people as possible (Fremgen, 2009; Rosenstand, 2003). The results are regarded as having a greater significance than the actions taken. In other words, consequentialism signifies that the ends justify the means. For example, if one would have to lie in order to save someone’s life, the act of saving the life would be morally sound while the act of lying would be justified through of the final results. “Utilitarians see as their moral guideline a rule that encourages them to make life bearable for as many people as possible” (Rosenstand, 2003, p. 175). This is an important quotation because it clearly states the guiding factor that the needs of the many outweigh the needs of the single person. The greater return for the least amount of effort, in essence an economic consideration, is of primary significance.

As applied to the scenario above, the lives of the scout troop would carry greater significance than the life of the single scout master. As a consequentialist, it would be necessary on moral grounds to assist the most people possible, even at the expense of a singular unit. Following this reasoning, it would be morally necessary to sacrifice the scout master and save the children. In this way, the greatest number of people is served while the least suffer.

Virtue-ethics reasoning is based on what a virtuous person would do; it deals with the character of a person and the responsibilities derived from such a character (Rosenstand, 2003). One concern of virtue-based reasoning is justice (Fremgen, 2009). According to R. G. Rodriguez, “Aristotle defined justice as being treated equally” (2009). Following virtue-reasoning, a virtuous person would act justly, therefore treating all equally. There would be no added value to one party or another.

As applied to the aforementioned scenario, using value-based reasoning would lead a person to the same conclusion as the other methods of reasoning, however for different reasons. The scout master holds ultimate responsibility for the lives and well-being of the troop that he leads. A responsible and virtuous scout master would have allowed the boys to exit first, therefore ensuring their exit before his own. Had he acted courageously, the boys would have been safely outside even had he then become lodged in the entrance; which would not have otherwise been fatal. However, justice would dictate that, as the responsible party, he would be sacrificed to save those for which his selfishness and lack of virtue harmed.

While all three methods lead to the same conclusion, the biggest dilemma with ethics is its subjectivity. There is no absolute right or wrong answer in many difficult situations; the morality is drawn from those involved and the examiners of the situation. This is especially important when considering healthcare ethics, often involving dramatic circumstances and choices. When applying different standards to healthcare practice, different conclusions may be achieved. It is important to understand all parties’ view points, to clarify the ethical issues, and to compromise in resolving the dilemma (Fremgen, 2003).

When determining who is right, it is important to consider the legal and sociopolitical context, including the professional codes of ethics. In this manner, the societal and professional obligations and expectations supersede the expression of the personal morality of an individual. For example, if a nurse feels that the morally obligatory course of action is to euthanize any cancer patient as a way to ease the financial drain on the economy (hence, utilitarianism as the societal needs serve a greater importance than a single person’s life), it would still be legally objectionable due to the standards of care, ethical code of conduct within the profession, and societal laws.

While all of the moral theories examined above result in the same conclusion, it is logical to consider some additional points that are relative due to the nature of the healthcare setting. The first thing to consider is the legality of the action: the paramedic would be operating outside of his or her scope of practice since they have no training on sacrificing a patient. Considering that the scout master is alive and yet unable to be extricated, it is reasonable to conclude that, even following the sacrifice, the paramedic would not be equipped to dismember the body in order to remove the scout master’s remains. In either case, this would be operating outside of the scope of practice, as well as violating the ethical principle of nonmaleficence (Fremgen, 2009). The paramedic would likely be sued in civil court, and may even be charged with murder.

Alternatives to executing the scout master may include dismemberment; losing a limb would be preferential to losing the life. Depending on the logistics of the scout master’s predicament, there may be time to find another way of extraction before the water rises high enough that the boys are mortally endangered. While ethics dictate one’s actions, it is also necessary to use all options available, to think independently and remain conscious of ethical and legal issues within the field (Fremgen, 2009).

References

Fremgen, B. (2009). Medical law and ethics (3^rd ed.). Upper Saddle River, NJ: Prentice Hall Health.

Kant, I. (1785). Grounding for the metaphysics of morals (Abbott, T. K., trans.). Retrieved http://philosophy.eserver.org/kant/metaphys-of-morals.txt

Rodriguez, R., Ph.D. (2009, November 9). Chat posting. Retrieved from AIU Online Virtual Campus. Chat 1 week 1.The ethical and legal aspects of healthcare: HCM410-0904B-02 website.

Rosenstand, N. (2003). The moral of the story: an introduction to ethics (4^th ed.). New York: NY: McGraw-Hill.

Physicians and caretakers are often faced with difficult dilemmas that require assisting patients and families to choose a specific course of action. Few environments are as demanding on the professional relationship as within medicine; treatment plans, end-of-life decisions and day-to-day recommendations balance risks with the patient’s best interests. Especially in the medical field, providers’ recommendations must maintain ethical standards. Ethical is defined at Dictionary.com (n.d.) as: “being in accordance with the rules or standards for right conduct or practice, esp. the standards of a profession”.

While persuasion is often used for beneficial or malefic purposes, as a method in itself it is amoral. However, given the responsibility of the vulnerable patient-doctor relationship, it is necessary to remain ethical and to avoid manipulation. Willingness to keep the patient’s best interests at heart helps create persuasive reasoning that is not only effective but also ethical. The key to ethical persuasion is motivation. Someone may persuade people to vote, knowing that citizens that are active in the selection of their representation will be happier than those who passively tolerate the rules and laws placed upon them. This persuasion has the audience’s well-being at heart, and would therefore be considered ethical. However, if the same person used strong-arm tactics, deception or manipulation to force people to vote for the persuader’s candidate, it would be unethical.

Persuasion can be ethical if all the facts, the pros and cons, are honestly presented. Persuasion is imperative, potentially leading to many beneficial ends, when it is done ethically. Ethical practitioners inform patients of the benefits of a treatment, prescription, surgery, or an action so that the patient can recognize just how well the idea, option or action will satisfy their need. Through ethical persuasion, patients should be able to face their fears and uncertainty in order to consent to the best options while staying fully informed of possible negative aspects of the course of action. By appealing to both the logical and emotional factors, the patient may be reasonably motivated to make the best choice.

For example: a pediatrician may persuade a parent to have their child receive a new vaccination. If the doctor maintains an audience-centered approach, keeping in mind the benefits to the child, this would be ethical conduct, following the standards of the profession. However, if the doctor did not fully disclose the risks of an elective procedure or vaccination, instead pressuring the parent with the intention of boosting their own treatment statistics, this would be unethical (and potentially illegal) behavior that is not within the standard of the profession. “To maintain the highest standards of business ethics, make every attempt to persuade without manipulating (Thill & Bovée, 2007, p. 308).”

References:

Ethical. (n.d.). Dictionary.com Unabridged (v 1.1). Retrieved September 14, 2008, from Dictionary.com website: http://dictionary.reference.com/browse/ethical

Thill, J. V. & Bovée, C. L. (2007). Excellence in Business Communication (7^th Edition). Upper Saddle River, New Jersey: Prentice Hall.

Over a period of many years, concluding with the bankruptcy of Enron in 2001, corporate and individual corruption and fraud cost shareholders millions of dollars (paraphrased, Einstein Law, 2008). “All of this debt was concealed from shareholders through partnerships with other companies, fraudulent accounting, and illegal loans” (Einstein Law, 2008). Because of the fraudulent business deals and special ghost companies that were created to hide the company’s debt, investors kept pouring more and more money into the stock. The artificial inflation of the stock price kept the executives rich, fed with outlandish bonuses. “Enron trussed up its corporate structure with hidden debt instruments, supported by the belief that reward could be divorced from risk (Steffy, 2008).”

Decision Making – Halo Effect

Enron was ranked as one of the top companies in the world. The corporate culture was both fun and challenging, and was viewed as the business model of the future (paraphrased, Ivanovich, 2004). Everything that Enron did appeared to be the best. “Fortune magazine named Enron the nation’s most innovative company five years running and, a year before Skilling’s resignation, ranked Enron among its ‘10 Stocks to Last the Decade’” (Ivanovich, 2004). The business was associated with its people, all of whom were top-notch. “The company also was obsessed with recruiting brilliant, aggressive people” (Ivanovich, 2004). In almost a hero-worship fashion, the brilliance of the executives carried over to the brilliance of the company. Everything looked perfect from the outside. The books looked great, and no one challenged the incredible profits that were being reported.

In retrospect, it is likely that stockholders and analysts should have been more cautious, scrutinizing the reports and actions of the company. I think that the primary reason that people did not investigate deeper into Enron was because of the halo effect. The people reacted to Enron because of the context-dependant stimulus (paraphrased, Plous, 1993). By seeing the executives as highly intelligent, brilliant and successful, fun and creative, the halo effect lead stakeholders to believe that they were also fair and ethical people, and that the business was run in a moral and ethical manner. Because of the halo effect, assumptions were made, based on the context of all the wonderfully positive things being said about the management; these assumptions eventually left employees and stockholders taking a major loss, facing long-term suffering.

Descriptive Models – Satisficing

Enron executives did not make the best decisions for the long-term good of the company or the collective. They did not even make the best long-term decisions for themselves, especially considering the lasting effects of their law-breaking on themselves and their families. However, I think that they chose their course of action by using the satisficing decision making model. “To satisfice is to choose a path that satisfies your most important needs, even though the choice may not be ideal or optimal” (Plous, 1993, p. 95). The executives committed fraud to fulfill their immediate need (or greed, in this case) for money. By fraudulently producing deceiving reports, they were able to keep a continuous flow of money into their own pockets. I imagine that the millions that they illegally gained helped to meet all their immediate needs, and to give the illusion of security. By choosing to address only their most primitive and narrow needs, without considering other all the other options that would be ideal or even optimal, the fraud committed is an example of satisficing.

Heuristics and Fallacy

Using the representativeness heuristic, people often judge probabilities by how much one thing appears to resemble another thing (paraphrased, Plous, 1993). However, this heuristic can cause problems when people fall into the “conjunction fallacy”, meaning that they assume that because there are more details, something is more likely to happen (paraphrased, Plous, 1993). In the case of Enron, I think that the executives used the conjunction fallacy of the representativeness heuristic to deceive the investors. With each additional factor, the probability is reduced (paraphrased, Plous, 1993); however many people feel that the more details the more likely something is. In the example of Enron, it created false companies to help hide its losses and substantial debt. By providing highly specific scenarios and ghost companies, many people did not question, but fell into the conjunction fallacy; assuming that, since there were so many details regarding the false companies, the lies must be truth. Fake companies, such as Chewco, JEDI, and Southampton (Einstein Law, 2008), helped to hide the billions of dollars of debt. By falsifying details such as the company names, stakeholders fell into the conjunction fallacy, and the executives were free to act as unethically as they wanted.

Another reason that I think Enron executives were able to execute such a grandiose fraud was because of their advantage using the availability heuristic. “People often use heuristics (or shortcuts) that reduce complex problem solving to more simple judgmental operations” (Schwarz, 1997). Using the availability heuristic, people judge probability on the frequency or prevalence of memory associated with a similar event (paraphrased, Plous, 1993). “The Enron mystique is due, in part, to the fact it was first in the recent wave of corporate scandals” (Ivanovich, 2004). Since there was yet to be a precedence of corporate fraud on such a massive level, no one suspected it. In fact, the company established such a reputation that its crash from on high was of tragedy proportions. Investors and watchdogs using the availability heuristic would not have perceived that such a massive fraud could take place, since there was no previous and readily available example of such events.

Overconfidence and Behavioral Traps

“Enron seems to have achieved primacy because it has all the earmarks of classic tragic drama, in which hubris causes the fall of the mighty” (Ivanovich, 2004). The mighty Enron, powerhouse and a sort of prince among large companies, became overconfident. The executives assumed that they would not be caught, that their deceiving and fraudulent tactics would continue without recompense. “No problem in judgment and decision making is more prevalent and more potentially catastrophic than overconfidence” (Plous, 1993, p. 217). Because the executives became overconfident in their own brilliance, they took risks that reasonable people would never enter into, particularly the defrauding of their investors, employees, and the general public.

Another major behavioral trap that the Enron executives fell into was the time delay trap. “When Kinder left and Skilling took over the presidency,” Strong said, “I started feeling that people were not looking at the longer-term perspective” (Fowler, 2004). Similar to saticficing, time delay serves only the short term, most immediate needs, without searching out the most ideal long-term decision. In this scenario, they fulfilled their immediate greed, but destroyed their futures, some by serving jail terms, another through desperation, shame and suicide (Einstein Law, 2008).

I would argue that a third behavioral trap that played a major role in this fraud was the investment trap. After completing the first fraud, they had little additional to lose to complete the second, the third, and so forth. Once the line was crossed into fraudulent and illegal behavior, it did not greatly affect the situation if they continued to behave in this way. Essentially, they had already invested too much, and could not withdraw from their immoral actions without even greater loss. Hence, it was easier for them to continue on the path than to withdraw and return to ethical business practices.

Yet another trap would be the collective trap. This small group of people benefitted greatly, but at a huge loss to the collective; costing not only the business entity, but the persons involved to suffer extensively. Lost jobs, lost wages, lost investments; stakeholders of all sorts were impacted by the selfish greed of this élite group. This trap seems to be especially cruel, since it shows a premeditated choice to injure so many other individuals. The evidence of the collective trap shows that the group of executives felt themselves above the rest, with a morally and ethically superior value.

The Social Side – Groupthink

I think that it is obvious that this group of executives fell victim to groupthink (Plous, 1993). Some of the most common symptoms that were demonstrated by the Enron group were: the illusion of vulnerability, collective efforts to rationalize warnings, and unquestioned morality (paraphrased, Plous, 1993).

Conclusions

There is no doubt that the Enron executives were brilliant, and that they used many theories and fallacies of common decision makers to extort and defraud millions of dollars from stakeholders. By utilizing their knowledge of the processes of decision making, they were able to mislead and manipulate the situation. They took advantage of the halo effect to make themselves look better than they were. They were satisficing; serving only their immediate needs. By exploiting the heuristics used by stockholders, they were able to continue to increase stock prices while the actual business portfolio plummeted. Their eventual downfall was a direct result of their overconfidence.

While it is embarrassing that such an event happened, it is important to understand how and why so that there is not a repeated scenario. Investors and the general public need to be aware of how immoral people can manipulate the situations, thereby controlling the cash flow. Awareness and knowledge are the best defense against such fraudulent behavior. These same concepts need to be applied to all aspects of healthcare; no department or field is beyond the possibility of flawed decision making.

References

Einstein Law. (2008). Enron fraud, the history of Enron, the Enron investigation. Retrieved 8 March 2009 from: http://www.lawyershop.com/practice-areas/criminal-law/white-collar-crimes/securities-fraud/lawsuits/enron/

Fowler, T. (2004). Enron’s implosion was anything but sudden. Retrieved 8 March 2009 from: http://www.chron.com/disp/story.mpl/special/enron/2655409.html

Ivanovich, D. (2004). Everybody knows Enron’s name. Retrieved 8 March 2009 from: http://www.chron.com/disp/story.mpl/special/enron/2655424.html

Plous, S. (1993). The psychology of judgment & decision making. New York, McGraw Hill.

Schwarz, S. (1997). SFB 504 glossary: heuristics. Retrieved 28 February 2009 from: http://www.sfb504.uni-mannheim.de/glossary/heurist.htm

Steffy, L. (2008). Meltdown highlights our own failings. Retrieved 8 March 2009 from: http://www.chron.com/disp/story.mpl/business/steffy/6038997.html

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