AMA Journal of Ethics^®

Since the foundations of medical ethics were laid in antiquity, the practice of medicine has evolved in tandem with the landscape of health care systems. Humanity’s wealth of contemporary clinical knowledge is accompanied by profound complexity in our health care systems, where diverse types of organizations (eg, hospitals, insurance companies, government agencies, private health investment firms) play equally diverse roles in acquiring and mobilizing resources. The significance of this complexity for health care ethics has become a subject of increasing scholarly recognition and analysis. Indeed, the integration of clinical and business ethics has produced an amalgam known as “organizational ethics.”¹

The interplay among hierarchy, management, and policy in current health care systems suggests that an organizational ethics lens is indispensable for appraising ethical problems.² How should organizations maintain reasonable expectations of professional employees? How should they promote ethical conduct of their constituents? How should they foster public trust in science and practice? The contributions to this issue of the AMA Journal of Ethics address these and other timely concerns in modern health care systems and illustrate ways in which ethical questions are often inextricably bound with organizational constituents, cultures, and relationships.

A fundamental difference between organizational ethics and traditional health care ethics is scope: traditional ethics focuses on individuals and organizational ethics on collectives.³ Relevant collectives in health care—including groups of clinicians, patients, nonclinical workers, administrators, and institutions themselves—have diverse and often overlapping memberships and interests that might conflict. Characterizing these collectives is a challenge: corporate organizations can be effective communities, and the aims of making profit and promoting public good can stem from a common purpose.⁴

Types of membership in health care collectives are multifarious; some groups exist by virtue of a common profession or place of work, others are voluntary associations providing a cohesive group identity (eg, labor unions). Where union membership is an option for physicians in training, affiliation might suggest to some physicians’ ethically relevant and possibly conflicting interests and obligations, especially when collective action (eg, striking) is considered.⁵

Where clinicians are employees, organizational culture can be understood as expressing organizational values and establishing and enforcing organizational norms. Moreover, organizations’ goals for ethical conduct can be taken to reflect individuals’ particular ethical values.⁶ Organizations can communicate and propagate these values through mission statements, and such values can then be used to justify organizational goals or leveraged to manipulate constituent attitudes.⁷ For better or worse, organizations can establish employee responsibilities and norms of conduct as measures for ensuring compliance.

Notions of transparency and trust surround relationships between health care organizations and outsiders. Contributions to this issue also address when—or whether—greater transparency begets greater trust⁸ and conflicts that can arise between a health care organization and an individual member.⁹ Institutional transparency and conflicts of interest can affect patients and constituents’ relationships—most importantly, those of clinicians and their patients.^10,11 Health care organizations’ interests and their potential conflict with interests of others under their authority are of great ethical significance, as partiality can threaten fiduciary obligations clinicians owe to patients. Moreover, health care organizations’ interests can differ significantly from those of entities external to health care (eg, private equity firms).¹²

Given uncertain futures for health care systems, we should expect organizational considerations to be central in designing and delivering health care services. We can look to this issue for guidance about ensuring reasonable expectations of clinicians,¹³ responsibly navigating clinicians’ collective negotiations with employers,⁵ enabling justifiable adjudication of disciplinary action against organization members,¹⁴ maintaining cultures that discourage misconduct,¹⁵ sufficiently communicating and responsibly leveraging organizations’ aims to promote shared decision making,⁷ crafting solutions when there are few or no alternatives,⁹ and maintaining good public relations to foster trust.⁸