The pre-conditions for "building capacity" in an ethics program.

Most organizations and/or their sub-units like ethics programs want to acquire the knowledge, skills and other resources needed to achieve their goals efficiently and effectively. Thus, they want to acquire or develop needed "capacity." But there are pre-conditions to building capacity that are often overlooked or forgotten, but which nevertheless, must be in place before capacity can be developed. This essay identifies these pre-conditions and discusses why they are necessary before attempts are made to enhance the capacity of any ethics program. The essay closes by offering a series of questions that ethics program leaders/and or members can asked themselves to assess whether or not these pre-conditions exist.

DNA-based patents: an empirical analysis.

The perception of rising litigation rates is driving the push for patent reform.

Tools for tomorrow's health care system: a systems-informed mental model, moral imagination, and physicians' professionalism.

Physician educators have been charged with incorporating systems-based approaches into medical education and residency training to help future physicians understand how their ability to provide high-quality health care depends on other individual and organizational stakeholders with whom and, in some cases, for whom they work. In part, this also requires that physicians accept that they have responsibilities to various system stakeholders. These changes are controversial because some fear they might distract physicians from their primary ethical obligation to their patients. However, systems theories and their applications in organizational management and business ethics support the notions that individuals can maintain primary professional ethical obligations while working within complex systems and that organizational systems can be constructed to support individual professional practice. If physicians are to commit to working within and, ultimately, improving systems of care as part of their ethical practice of medicine, then they will need a new mental model. Leading thinkers have used various models of systems and have highlighted different aspects of systems theories in describing organizations, groups of organizations, and organizational processes. This essay draws from these models some basic concepts and elements and introduces a simple but comprehensive mental model of systems for physicians. If it is used with professionalism and moral imagination, physicians might have a tool that they can use to understand, work with, and, ultimately, improve the systems of care that they rely on in their practice of medicine and that critically affect the welfare of their patients.

Role of organization ethics in critical care medicine.

The authors view the activities involved in critical care medicine as composing a complex adaptive system that is itself operating within a complex adaptive system, the healthcare organization. The authors explain why it is necessary that these systems be viewed this way, and they explain what is necessary to allow them to produce creative or emergent outcomes. They provide a justification for the role of an organization ethics program within this context. They provide a definition of organization ethics and outline the characteristics that an effective organization ethics program would possess.

The CREATE Act: increasing costs associated with the biotech industry?

A new law intended to promote collaborative research may end up costing the biotech industry more and inhibiting innovation.

The Rashomon effect: organization ethics in health care.

The Academy-Award winning 1950 Japanese movie Rashomon depicts an incident involving an outlaw, a rape or seduction of a woman, and a murder or suicide of her husband. A passer-by, who is also the narrator, explains how the story is told to officials from four different perspectives: that of the outlaw, the woman, the husband and himself. The four narratives agree that the outlaw, wandering through the forest, came upon the woman on a horse being led by her husband; the outlaw tied up the husband, sex took place between the woman and the outlaw in front of the bound husband, and the husband was found dead. The narratives do not agree on how these events occurred or who killed the husband. The outlaw contends that consensual sex occurred between him and the wife, and he claims to have killed the husband. The wife depicts the sex as rape and claims that because of her disgrace she killed her husband. The husband, through a medium, says that the sexual act began as rape and ended in consent, and that in shame, after being untied by the outlaw he killed himself. The passer-by's story agrees with the husband's account of the sex and the bandit's account of the murder. Because the passer-by is also the narrator of the film, we tend to believe his version. But what actually took place is never resolved.

Evidence-based medicine: why clinical ethicists should be concerned.

Evidence-based medicine purports to be the integration of three prongs; best research evidence, clinical expertise, and patient values and preferences. Controversy still surrounds the application of evidence-based medicine and undoubtedly controversy will persist in the treatment of specific diseases, thus allowing for some flexibility in decision-making. Yet, the idea that variation is expensive has gained wide acceptance and variation can best be controlled through rigid systems. So given the financial constraints facing healthcare organizations, as well as pressure from such august organizations like the Institute of Medicine to implement evidence-based medicine, flexibility in decision-making may ultimately become the exception rather than the rule. Certainly, in the short-term, the advantages of a rigid system, notably its cost advantage, overwhelm the advantages of a more naturally adaptive system--and so where possible evidence-based medicine will probably be implemented within a rigid context. Rigidity in system design will affect the activities of clinical ethics. To be effective in such a system, clinical ethicists will need an understanding of the system within which they practice including its values, goals, operations, and tools. This is a knowledge area which few in this field currently have and which they may not wish to acquire. But, if clinical ethicists expect to have credibility in responding to these changes, they must understand the values, goals, processes and outcomes of the system in place and be able to advocate for greater flexibility and greater attention to patient values and preferences even within a rigid mechanical system.

Stakeholder expectations in practice-based medicine.

Competitive pressures are forcing physicians from solo practice into new organizational structures. These new structures and the technologies supporting them have generated suggestions for improving medical practice. This article examines the unspoken assumption often accompanying these suggestions that practice improvement can come about through a closer alignment of the practice's goals and values with its stakeholders' expectations. Because conflict among competing goals is inevitable in a resource-scarce environment, an important question for each practice, and for each individual physician in a practice, is how to adjudicate conflicts of value when the goals of the practice appear to collide. This essay concludes with a proposal for an adjudicating process to help resolve these conflicts in practice-based medicine.

Total quality management and the silent patient.

This essay examines the impact of the imposition of businesses techniques, in particular, those associated with Total Quality Management, on the relationships of important components of the health care delivery system, including payers, managed care organizations, institutional and individual providers, enrollees, and patients. It examines structural anomalies within the delivery system and concludes that the use of Total Quality Management techniques within the health care system cannot prevent the shift of attention of other components away from the enrollee and the patient, and may even contribute to it. It speculates that the organization ethics process may serve as a quality control mechanism to prevent this shift and so help eliminate some of the ethically problematic processes and outcomes within the health care delivery system.