The Hard Road of Ethics

The issue of workforce reduction is one that rings close to home for me. After reading Chapter 5 in The Tracks We Leave which addresses workforce reduction, I had several distinctions that became evident as a result of my past experiences.

In my days of working as a pharmaceutical rep I learned so much about company culture, managing people (what not to do more than what to do) and how long term businesses should be run. My time in the Master’s program at UCF has been critical in understanding my past experiences from a business perspective and what I can learn from it all.

The chapter on workforce reduction particularly struck a chord with me. When I worked at the pharma company I got a crash course in what it was like to work for a morally depleted organization. When I was hired to work there in early 2008, the company had already had one layoff the year before and by the time the fall of 2008 rolled around there was already talk of another reduction. And it was true. There was another reduction.

I survived that round despite my non-existent tenure but the remaining days at the corporation proved to be extremely demoralizing. The company was the perfect example of an organization that overused corporate jargon like “we value transparency” and “integrity is king” but the actions of the leadership team were so contradictory. Some managers used fear and manipulation to control team members and senior executives would outright lie about the state of the company when the entire workforce knew that we were in trouble.

By the time they were ready to have their next layoff in the summer of 2010, I volunteered to leave and took my severance pay because I couldn’t foresee spending another day working for such a compromised organization—compromised in integrity, that is. Once I left, I started a business with my husband and it has been the best decision that I’ve ever made.  

What I’ve come to realize throughout this course (in a new way) is that to be an organization of excellence it’s HARD. It’s hard to always do the right thing when no one is watching. It’s hard to be ethical with all employees. It’s hard to take on the humility that is required to be an outstanding leader. It’s hard to make ethical decisions that may not benefit the company but they are the right thing to do. Because of these challenges many organizations concede to the pressure of running a business.

One of the most significant things that I’ve realized throughout this course is the diligence and persistence that is required for an organization to uphold itself to the highest ethical standards. My goodness, reading through some of the case studies in The Tracks We Leave left me dumbfounded. Considering all of the stakeholders and the values of the different individuals in an ethical dilemma is taxing. It requires a lot of thought and conscientiousness. It can’t always be a swift decision—especially in health care where answers are not always black and white. I at least feel like I am more equipped to handle such dilemmas and as I grow in this area it will become easier and easier.

My belief is that leadership teams need to understand these challenges. Not just the challenge in recognizing the ethical dilemma from different perspectives but the challenge of actually doing the right thing. Sometimes corporate conferences and ethics campaigns can oversimplify this to the detriment of the leadership team. If it were as easy as some are led to believe, then overall we would see a more equitable and integrity-based workforce. It is the responsibility of the leadership to make the commitment to do the hard work of upholding ethical decision making even when it may not be popular to do so. 

My Real Thoughts on the Debate

I enjoy debating and this is the second course in the Master’s program where I’ve been able to debate as a part of the course content. It’s always challenging to debate when you don’t necessarily agree with the topic that you’ve been given. It’s interesting because toward the end of the debate I actually started to believe my arguments! (Maybe that means that I argued my points well). :-)

Out topic was that health care professionals should not be exempt from patient situations where they have conscientious objections. The more I learned about this topic the more I realized how challenging it is. On the one hand you have health care providers who also have a conscience and a belief system that may not necessarily “gel” with that of the organization. And on the other hand you have the organization that wants to make sure that there is order and process and more objectivity than subjectivity. That’s what keeps them protected legally and otherwise. Of course, in the midst of all of this is the patient’s wellbeing that must be considered. It can be a pretty challenging situation.

I had a few primary issues with both sides of the arguments. First, the argument of the pro side was that no individual should be required to act against their conscience. I don’t agree with that at all simply because of the varying perspectives of what is right and wrong from one person to another. In my argument I frequently cited a study of psychologists who had done some very unethical things in the name of patient welfare and their “deeper values” (i.e. their conscience). Sometimes I think that because doctors are doctors we automatically believe that they have sound judgment. This is not always the case and leaving a doctor too much wiggle room on what they believe to be morally right is a risky situation.

I also have issues with my own argument which says that there is too much subjectivity in allowing doctors to remove themselves from certain situations where they have a moral conflict. It’s true that there is a lot of subjectivity there, but I also believe that in many cases that is exactly what the health care system needs. To leave everything to objective measures, laws and regulations implies that we have a perfect system—that if we just follow the rules of the system that in the end it will all work out and everyone will be happy. This is not always true and even if the goal is not for everyone to be happy, but it’s to uphold the patient’s best interest that doesn’t always happen either. We’ve all heard stories of the drama that people go through with insurance companies or taking a prescription drug that causes harm to the patient.

In my opinion, there’s no real way to be on one side or the other when it comes to professional rights and conscientious objections. In reality, I tend to lean somewhere in the middle of the pro and con sides. We can’t use health care provider rights as a default position nor can we use the perspective of solely relying on objective means to determine what should be done. It requires an evaluation of the situation, case by case. That means that there’s no cookie cutter approach and organizations like cookie cutter because there’s certainty there and it’s less costly. But in this case, evaluating the situation on an individual basis will be the best way to move forward. 

Not Everyone Can Be a Mother Theresa

This week for my mini paper I chose to discuss a topic in ethics that may not be discussed very much: the real cost of ethics. Organizations that have high ethical standards are more long term sustainable than those that do not. I believe this because I’ve read articles from brilliant researchers like Jim Collins as well as others and I have worked for an organization that did not have high ethical standards and witnessed their steady decline as an industry powerhouse for the 2 ½ years that I worked for them. I truly believe that when organizations are run with integrity that it is beneficial to the company, the leaders and everyone working in it.

That said, I also think it is so important to have a dialogue around ethical decision making that takes into consideration a “real-world” point of view. Learning about codes of ethics and what is ethically right in certain situations is extremely important. If you don’t know the “rules” of the game then how can you play? But it takes strategy to win. And my internal dialogue has really been kicked into high gear by reading some of the ethics scenarios in The Tracks We Leave as well as some of the situations I have read about in my own research.

I don’t think that one can neglect office politics for the sake of ethics and vice versa. Similarly, it’s important to carefully consider the consequences of any ethical stance that one may take in a situation. The reality is that not everyone has the luxury of calling attention to every unethical action that is observed in the workplace. I believe that Marilyn Moats Kennedy said it best:

“It is commendable to stand up for what’s right, but before you do you should calculate the costs and make an informed decision before you act.”

Agreed. After reading some of the ethical dilemmas that were mentioned in the book I thought about what (if anything) I would have done differently had I been in that situation. A few weeks ago I blogged about the scenario with Jim at Qual Plus HMO and how he could have been a little bit more discreet in his questioning of the Board’s motives as opposed to calling Legal and the Ethics committee outright. This likely caused some waves as there is a high probability that his actions were “leaked” by those he confided in. Checking in with a trusted colleague may have been a better first step and toning down his seemingly indignant posture might have helped him out as well.

In the case of John at Rolling Meadows Community Hospital I just had to shake my head at the fact that he told his female protégé that he couldn’t hire her because there was a sexual attraction on his part and then insinuated that she had similar feelings! Honesty is important but he could have easily reframed his words so that he wasn’t being dishonest and at the same time he would have protected his career and saved his wife and the protégé the embarrassment of what was to follow.

In my view, John was under no obligation to hire her and in fact he most likely should not have due to the situation that he was in. At the same time, he could have just said that he was not prepared to offer her a position at that time (which would have been true) and that he would be glad to help her find positions at other organizations. Simple solution and it doesn’t get messy. This is called emotional intelligence and it cannot be left out of the conversation when we’re talking about ethics. I think that this fits into what Perry may be alluding to when he discusses the importance of context in chapter 1a, “Deciding Values.”

An interesting real life story of “the cost of ethics” actually took place in Florida. David Cray took a job with a company called Nations Securities. When he was hired he took over an old rep’s accounts and noticed that a lot of the customers were angry because they had been sold mutual funds when they thought they were getting a different type of account. He was very concerned about this and ran it up the flagpole to the higher ups. Long story short, after persistently raising the issue he ended up getting fired from his job and years later when the case was being settled (he had sued his former company for firing him) he was awarded NOTHING. Keep in mind, he lost a 6 figure income, was blacklisted from his industry and his wife ended up losing her job shortly after he lost his they believe because of the situation with his former company.

He started up his own brokerage business that was struggling and he was paying out thousands of dollars a month in lawyer fees not to mention all of the money that had been lost from his previous income and his wife’s. They dipped into their savings for years to be able to make ends meet and in the end were not compensated in any significant way for all of the pain and suffering that they endured.

This is an extreme situation, but a reality no less which is why it’s important to count the cost. I’m definitely not saying that people shouldn’t do the ethical thing if it costs them anything. I believe that we need leaders that will stand for what’s right in extremely challenging circumstances. And it’s important to ask yourself, “On the continuum of sacrifices for ethics and integrity, what am I willing to give up?” I think that everyone would like to believe that they are like the Martin Luther Kings and Mother Theresas of the world—who would give up their very life for what they believe to be right. But, the reality is that the vast majority of people do not have that level of conviction and that’s fine. Not everybody can be a Mother Theresa. However, what we all need is to have the honesty to confront ourselves and find out what exactly we are willing to sacrifice and give up for our values and convictions. We can reach higher and higher levels of internal morality but the important thing—what will help us to deal with what we are facing today—is to find out where we are on that continuum right now.

Reference
Perry, F. (2002). The Tracks We Leave. Chicago: Health Administration Press.

The cost of rebuilding a career. By: Sullivan, Suzanne, Longo, Tracey, Kiplinger's Personal Finance Magazine, 1056697X, Feb96, Vol. 50, Issue 2

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Will Health Care Reform Be An Ethical Win For America?

As I continue to work through the readings each week and read about the different ethical scenarios it’s very clear that the underlying source of many ethical dilemmas in health care is due to the fact that health care is a business and it’s also meant to serve the community. Many of the examples in the two books we are studying are meant to highlight the difficulty of running a business (especially a for-profit business) in an industry where people expect that society will be supported first and profits second.

I am a business owner of a health consultation company and I found the perspective of “cherry picking” in advertising on the part of Managed Care Organizations (MCOs) to be very interesting. The point was that MCOs should not solely seek out healthy individuals that have a low probability of needing coverage.

I thought to myself, “Why wouldn’t they have that approach? It’s the most profitable way for them to run their business?” And frankly, I’ve never thought of MCOs as being organizations that have the greater good of the people at the forefront. But, why are MCOs expected to advertise their services to everyone and other health care businesses don’t have this same expectation?

For example, is anyone keeping tabs on who walk-in clinics are advertising to? What if they aren’t marketing enough to underprivileged markets in their area? Is it wrong if they target upper middle class families for their services and not others? What if that makes the most sense for them from a business perspective? It’s important, after all, that they do stay in business.

What I find is that certain public interest groups expect organizations like big MCOs, pharma companies and other for-profit organizations to behave as if society’s wellbeing is their first priority. However, for the most part these organizations operate with the primary motivation of making profits and helping society is second, third and sometimes last on the list.

Should society expect these for-profit organizations—multi-billion dollar companies with their shareholder interests to operate with the wellbeing of society as first priority? Personally, I think it’s silly to keep expecting that.

Now, I don’t mean to say that companies should be given free rein to do whatever they want. There are certain boundaries that need to exist—drugs still need to go through clinical trials and there should be regulations about the claims that companies can make about what their products do and what they are indicated to treat. However, I don’t think people should keep expecting big MCOs and big pharma to start acting like Mother Theresa.

With all of this in mind, I wonder if the best thing we could do is to have a socialized health care option such as the one that President Obama has proposed. Now, I’m not saying that the bill is flawless and it may be a total flop in the end. However, it seems that society is expecting for there to be more health care institutions that have their interest in mind and not profits as first priority.

I know that the government can really make a mess of things if they get too involved, but I’m starting to wonder if the reform is exactly what the country needs. What if, on an ethical level for the citizens of America there was a place that everyone could go to get covered for health care? And the organization that provided it didn’t have the pressure from shareholders or any other for-profit objectives that private health organizations have? It’s not a perfect model, but maybe it’s better than the one that we have. It’s all theory, but it will be interesting to see what happens.

I’ve wanted to write about the situation with Jim at Qual Plus HMO. It was a pretty challenging situation and there were a lot of factors involved, two of the most significant being peer pressure and office politics.

When I first read through the scenario, my gut instinct was that it was definitely unethical for Joe to make a motion that the contractors provide their “final bids.” This is especially unethical considering his relationship with ACME construction, that a protocol had already been established for the whole process, and that he had already seen all of the bids.  I could empathize with Jim’s feelings that it was wrong to change the process at the last minute.

I read the outcome of what actually happened in the epilogue. Jim was ostracized and it seemed that he was being “managed out” of the organization. I thought about what (if anything) I would have advised him to do differently.

I worked in the corporate world for about 2 ½ years for a major company so I am very familiar with the political quandaries and the pressure to “play the game” in order to survive. I think that that pressure increases the higher you climb in a company and with that, the stakes also get higher.

What I’ve come to realize is that people don’t like feeling as if someone else “has dirt on them”—information about their behavior or choices that could compromise their career or how they are viewed by their superiors or colleagues. If an unethical choice is being made, they want to feel like everyone is “in on this together” and that nobody is going to be the tattle tale.

Jim did not leave this impression at all. It started when he “questioned the rationale, legality and ethical implications” of the decision to let the contractors provide final bids. Because he was “astonished” by the board’s actions he may have been communicating in an indignant way. I’m sure this would not have been received well.

He then proceeds to speak with the company’s attorney, the CEO of the company and the ethics committee about the decision that was made. No one seems to find anything wrong with what has happened, but at this point Jim may have made too many waves.

In corporate politics, a lot goes on behind the scenes and there can be more going on in a situation than what it seems. The attorney could have called the CEO and let him know about the call from Jim. The woman at the ethics committee could have told someone that Jim called her about the issue and word could have travelled through the “corporate grapevine” that Jim was making a big deal out of nothing and that he’s not a “team player.”

I think that Jim should have initially tried to be much more discreet so that he could still get his questions answered without creating this big stir. I think that he is being managed out because the higher ups have determined that he’s too much of a “goody two shoes.” We already know that there is some unethical behavior going on with Brent (the CEO) and the board members. These guys don’t want to feel like someone is “watching them” ready to call legal or the ethics committee to report their behavior.

It would have been ideal if Qual Plus had some kind of ethics line where employees could call in anonymously and have their questions answered. That way they don’t run the risk of being ousted by their colleagues or superiors and it’s on record that they did the moral thing by calling the action into question.

As far as whether Jim should have fought to the end for what he believed to be right, I think it’s a matter of personal conviction and what you are willing to risk. Hoffman and Nelson say that risk taking is part of integrity (p. 11). But how much one is willing to risk is a personal decision and even ethics can’t define any cut and dry rules that should apply to all situations.

In this case, I don’t think that I would have risked my job to fight for proper procedure in the construction bidding. I do believe that Jim had a moral obligation to ask someone else what should be done and I would have done the same, but it would have been best if he could have done it anonymously or if he could have “kept his cool” a little bit better.  Ethics is very important, but it doesn't always have to be in direct opposition of keeping your job. 

I wrote my mini paper on the ethical challenges of the pharmaceutical industry—specifically, the issue of gifting physicians with lunches, dinners and office supplies. I used to be a drug rep so I can speak on this with some authority.

I came into the industry in 2008, so I never saw the extravagant gifts like vacation packages and tickets to Orlando Magic games. My company had done away with that in the mid-2000s due to a great deal of pressure (and scrutiny) from the general public.

I did, however, bring doctors and their staff lunches, take them out to dinners and supply them with pens, notepads, medical instruments and other drug paraphernalia. I remember the looks on the patients’ faces when I would walk into a packed waiting room bringing bags of piping hot food from Macaroni Grill. The looks I got were not very nice.

In 2009, the pHRMA organization, a pharmaceutical advocacy group, announced that they were changing their code of ethics in terms of what was appropriate in rep interactions with doctors. As a result of their updated code, several companies (including mine) got rid of the notepads, pens and many of the other office supplies that we were giving doctors. We were only allowed to give educational material (like a poster on the common causes of asthma) and lunches and dinners had a spending threshold where before it was pretty much unlimited.

Pretty much all of the big companies agreed to the new code of ethics even though it was voluntary.  I assume that Pfizer didn’t want to look bad if GlaxoSmithKline was going along with the changes. So the heavy hitters all jumped in.

Even though my company made changes in how reps interact with physicians, I don’t feel like it really helped that much. Perhaps it helped in a very small way with public perception of pharma (and that’s why I think that they all did it—for the publicity) but it did very little to influence the culture of the organization.

When a company is built on deceit and dishonesty, twisting the truth when it benefits them and encouraging employees to “tell the best story” when selling their products it will not turn into a morally upright company simply because the leaders have decided to stop giving notepads to doctors. Despite the change of several big pharmaceutical companies to adopt the practices of the pHRMA code, there is absolutely no shortage of drug industry scandals, off label promotions and FDA sanctions for misconduct.

The pharma industry was one of the most corrupt and backward industries I have ever worked for. However, I do consider it an extremely valuable experience in terms of my development as a leader and as an individual and I would never take it back. I gained clarity in what I stand for and believe in and I learned that company culture is extremely important. Leaders have to BE what they want to see in people instead of offering lip service and industry buzzwords to create the “feeling” (not a reality) of being an outstanding company.

I truly believe that good ethics in a company starts with great leaders, which is why I’m really glad that I’m taking this course and learning how to develop myself in this area.

My husband and I often watch TedTalks on our Apple TV. About a month ago, they had a very interesting speaker by the name of Atul Gawande. He is an author and surgeon and his talk was about the many issues that plague the medical community, particularly the occurrences of incomplete and inadequate care. He discusses the attitudes amongst the physician community and how certain ideals of perfection can impact behaviors.

I thought that his talk echoed some of the same concepts discussed in the medical errors chapter (pp. 160- 161) of Managing Ethically. In this chapter Dr. Morreim discusses the legal and ethical imperatives in dealing with medical errors. He notes that the healthcare culture views doctors as error-proof gods and this is similar to Gawande’s perspective in the TedTalk. Gawande also acknowledges that the physician community places in emphasis on being a “cowboy”—kind of like the “answering to no one” mentality—and how this attitude belittles the importance of rules and structure.

What I find to be very interesting is how this attitude can prevent physicians and medical staff in general from taking the ethical high road in situations. If doctors are held up to a standard of perfection, I would think that they would be much more likely to hide their errors or downplay them so that they save face in front of their superiors and colleagues. This is damaging not only to the patient who may be harmed as a result, but it also does not allow for the improvement in systems due to fear of judgment or repercussions.  

Perhaps these attitudes are the reason why public records of physician errors are so controversial. In a culture where perfection is the standard, any doctor would be fearful of losing patients because of this information going public.

I think that there are several ways to help deal with this problem. Firstly, healthcare managers need to be intentional about creating a culture of teamwork. Doctors do not do their jobs alone. They rely on nurses, other physicians and a full staff of people to help them succeed in caring for patients. The healthcare environment should place more emphasis on teams and less on individuals. Certainly, there are times when individuals need to be praised or held accountable for their actions, but all around a culture that focuses more on teamwork could be helpful.

Additionally, managers need to create a safe environment for error reporting.  The staff should feel comfortable reporting errors without fear of being punished or judged. The more employees share in this area the more a hospital can improve in their systems.

Finally, I like the suggestion that Gawande makes in his TedTalk video: checklists. There are a variety of strategies that can be used for reducing medical errors, but Gawande notes that even in surgery using checklists decreased complication rates by 35% and death rates by 47% in hospitals that implemented the technique. He agrees that overcoming physician attitudes around checklists will be a challenge, but the outcomes of this idea appear to be promising.

I’m sure that there are many more ways to reduce errors in hospitals, but a key aspect of that is to create a culture where people feel comfortable admitting that they made a mistake.

The Ted Talk Video is below.

Ethics--A Not So Black and White Topic

I never took an ethics or philosophy course in school so these concepts are all new to me which is exciting. When I think of the word ethics, typically I associate that with examples of unethical behavior as opposed to positive examples of ethical behavior. This is most likely because the negative examples get all the media attention (Enron, Wall Street, etc.).

I worked for a major pharmaceutical company for a little over two years and I would have to say that in my role as a sales rep I have never experienced more ethical challenges. Every day I was faced with decisions about whether or not to skew the truth a bit, over exaggerate or sometimes even outright lie. It was a very interesting situation. I was working for an organization that prided themselves on being “transparent”’ and honest in the midst of many other (pharmaceutical) companies that were being flamed by the press for hiding life or death clinical information from the FDA.

It was a cynical environment to work in and pretty much the entire 2 years that I was there the morale of the company was very low. I remember when rumors started leaking that my company had (illegally) tested vaccines on indigenous tribes in Africa. I remember one drug scandal after another that broke out and the reports of reps selling drugs “off label.” I remember the scowls on patients’ faces as I brought in big bags of catered lunch to offices along with lots of pens, notepads and other drug company paraphernalia.  Looking back, I don’t blame them.

As I read over the Basic Ethical Terms and Normative Theories I couldn’t help but think about my days as a drug rep. I find that some of history’s greatest transgressions have been justified by the “greater good of the people.” There are so many ways to argue what may be right or wrong or what makes something “good.” To me, the greater question is whose perspective is deemed to be most important which the writer of the website points out. This is a key point in differentiating the three Theories of the Good (utilitarianism, care ethics and ethical egoism).

For example, a drug company could justify illegally testing vaccines in humans because even though some may die or suffer terrible consequences, the greater good is that much more people will benefit from the “advancement” vaccines bring to medicine. This is utilitarianism.

If I were a person that was being subjected to that testing, I could talk about my rights as an individual and the unfairness of being forced into a potentially dangerous situation. I would be arguing for my own self-interest and this is ethical egoism.

In these two situations few people would argue against the fact that the pharmaceutical company is wrong and the individual is right. But what happens in situations that are not life or death?

For example, Iet’s say a colleague conveys in confidence that they are cheating the company in a way that is putting the organization in serious financial risk in order to pay for his five year-olds leukemia treatment. And let’s say that this should be covered by the company insurance, but due to budget cuts the company has had to scale back on insurance plans.

Should you tell your supervisor what’s happening? You know that your colleague will be fired and then how will their child’s treatment be paid? Are you being unethical by not sharing this? Should you tell? You know they’ll be after you if they find out that you knew and didn’t tell someone. So many things to consider!

It seems that ethics is this big conundrum of trying to balance all of the different perspectives involved in any given scenario. It is inevitable that the outcomes are not always fair. There is no clear right or wrong in many situations and it takes a lot of good judgment to be able to decipher what is appropriate for each circumstance. As a leader, I hope that this course gives me insight into how to discern ethical dilemmas in an appropriate way.