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"Service excellence is based on ethical service."

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Topical Bibliography | Home Care Ethics Self-Test
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An Introduction to Administrative Ethics

Ethics is a hot topic these days. There is a deluge of input. Home care managers do not need to be ethicists. They need to be able to identify problems quickly, and know how to prevent them. They need to understand the tools available, and to recognize the areas of risk.


Bioethics guides caregivers. It uses principles for framing ethical issues in any case. These are:

1. Autonomy - Individual dignity, self-determination, and rights. Will a particular course of action lead to anyone being used as a means to an end without regard for their individual rights?
2. Beneficence - Doing the greatest good and balancing the risks and benefits. Caregivers have an obligation to benefit the patient.
3. Non-maleficence - Minimizing harm ("primum non nocere"). Caregivers must avoid causing harm and strive to protect the patient from harm.
4. Justice - Fairness, equitable use of resources and equal access to care. Individual need justifies who gets what and how much. Individuals or groups are similarly treated.

There are two approaches in bioethics. Deontology is concerned with duty and the use of principles, especially beneficence, non-maleficence, and justice, to deal with problems. Teleology or utilitarianism is concerned with consequences and uses beneficence in seeking optimal outcomes. Bioethics asks: What should I do in regard to a patient or patients for which I have some responsibility?

Administrative Ethics

Administrative ethics is concerned with how providers influence the ethics of their members, how the members influence each other and the organization, and how the members and organization deal with the community and government. It is a new branch of bioethics addressing the corporate context in which decisions are made by providers. It asks: How can a provider assure compliance with its values and ethical behavior by its members? The distinction between bioethics and administrative ethics is shown below:


* Duty to specific patients
* Rights of specific individual patients
* Caregiver duty to professional competence
* Caregiver compliance with professional codes

Administrative Ethics

* Duty to those served
* Patient rights and provider rights
* Provider commitment to quality and standards
* Provider compliance with values and laws

Administrative ethics at work: There are three ways that organizations influence ethical behavior: (i) requiring performance of unethical or illegal acts; (ii) unrealistic performance expectations; and (iii) being unclear about what is ethical and offering little guidance. Administrative ethics is a framework for producing outcomes that ethically empower stakeholders and deter illegal behavior. It provides instruments to accomplish this goal. These include:

* Value statements and philosophies
* Ethics codes
* Ethics education and training
* Ethics committees
* Staff ethicists and consultants

An administrative ethics conflict: It is a situation in which an individual is faced with a decision that is incongruent with the provider's values or constitutes a possible violation of the law. The conflict can be the result of a policy, plan, or up-line mandate. It is an sign of an underlying ethics issue in the organization. An ethics issue can arise in the form of an ethics problem or an ethics dilemma.

An administrative ethics problem: It is a matter of "right and wrong." There is clarity and certainty about the individual choices. "Wrong" is: (i) breaking the law (administrative, civil, or criminal); (ii) violating an organizational policy; (iii) failing to fulfill a responsibility; (iv) being dishonest (lying or withholding information); or (v) breaching a value or ethical principle. An individual faces an ethics problem when he or she is put in the position of having to do any one, some, or all of these things as a result of their place in an organization.

An administrative ethics dilemma: It is a situation in which (i) any possible action would involve harm or (ii) the decision maker must choose from two or more options, all of which may be inconsistent with personal values as well as the agency's or company's values, or (iii) the only available course of action involves unethical and/or illegal activity. Ethics dilemmas tend to involve such choices as:

* Honesty versus loyalty
* Individual need versus organization need
* Short-term versus long-term gain
* Justice or fairness versus compassion or caring

Steps in resolving an ethics conflict

An administrative ethics conflict is a problem within an agency or a company. Its cause may be motivated by outside factors (e.g., competition), but it is an internal matter. We proposes a six step process for use in resolving such conflicts:

1. Determination and acknowledgment of the conflict
2. Definition and documentation of the conflict
3. Clarification of the nature of the conflict (i.e., ethics problem or ethics dilemma)
4. Identification and verification of the process responsible
5. Identification of alternatives for resolving the cause
6. Selection and implementation of a course of action

Administrative ethics problems tend to be non-routine, diffuse and nebulous. Administrative ethics belongs in every manager's resource inventory.

Administrative Ethics: A Guide for Home Care Providers

HCMA, Ltd.

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[Home Health Helper]

Ethics Self-Assessment for Home Care Providers

1. You give your patients a standard unit of service (e.g., two hours of skilled HHA care, supplies, etc.) because that is what "everybody else does?"

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

2. You accept referrals regardless of the availability of qualified staff to provide timely service.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

3. You or others sign orders or certifications that have not yet been returned by the physician because an external surveyor is due to visit your office.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

4. You unquestioningly implement policies or procedures developed by your agency or company even though you personally consider them to be wrong.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

5. You or others with your knowledge spend evenings updating records and QI reports to demonstrate "compliance" rather than fostering consistent documentation practices.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

6. The "numbers" (i.e., sales objectives) are the dominant factor in your decision-making in regard to the care, services, or products provided to patients.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

7. You overlook actions of a superior which you feel may be at odds with agency or company policy rather than risk reprisals.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

8. You feel that it really does not matter what you do because your agency or company is too small for anyone to be concerned about.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]

9. You seek the advice of others when you encounter a decision or issue that you feel may conflict with agency or company values, or may be unethical or illegal.

Routinely [ 2 ] | Sometimes [ 1 ] | Never [ 0 ]

10. You compel staff to do things that they may individually consider to be unethical.

Routinely [ 0 ] | Sometimes [ 1 ] | Never [ 2 ]


16 - 20..... Ethical Upper Echelon
11 - 15..... Ethically Safe and Sound
5 - 10..... Ethically Challenged
0 - 4..... Ethically Oblivious

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A Topical Bibliography

Administrative Ethics

Bulger, R. J., And Cassel, C. K., "Health Care Institutions" in Reich, W. T., (Ed.), Encyclopedia of Bioethics, New York: Simon & Schuster Macmillan, 1995 (Revised Edition) Vol. 2, pp. 1046-1049.

Darr, K., "Administrative Ethics and the Health Services Manager" Hospital & Health Services Administration. March-April 1984 (29) pp. 120-136.

Darr, K., Beaufort, B. L., and Rakich, J. S., "The Ethical Imperative in Health Services Governance and Management" Hospital & Health Services Administration. March-April 1986 (31) pp. 53-66.

Potter, R. L., "From Clinical Ethics to Organizational Ethics" Bioethics Forum. Summer 1996 (12) pp. 3-12.

Reiser, S. J., "The Ethical Life of Health Care Organizations" Hastings Center Report. November-December 1994 (24) pp. 29-35.


Beauchamp, T. L., and Childress, J. F., Principles of Biomedical Ethics. (4th Edition) New York: Oxford University Press, 1994.

Beauchamp, T. L., and Walters, L., Contemporary Issues in Bioethics. (4th Edition) Belmont, CA: Wadsworth Publishing, 1994.

Wolpe, P. R., "The Triumph of Autonomy in American Bioethics: A Sociological View" in R. DeVries and J. Subedi (Eds.), Bioethics and Society: Sociological Investigations of the Enterprise of Bioethics, New York: Prentice-Hall, 1997.

Business Ethics

DeGeorge, R. T., Business Ethics. New York: Macmillan, 1990. 3rd Edition.

Ferrell, O. C., and Fraedrich, J., Business Ethics: Ethical Decision Making and Cases. Boston: Houghton Mifflin, 1990.

Gellerman, S., "Why ‘Good’ Managers Make ‘Bad’ Ethical Choices" Harvard Business Review. 1986 (July-August), pp. 85-90

Tuleja, T., Beyond the Bottom Line. New York: Facts on File Publications, 1985.

Trevino, L. K., and Nelson, K. A., Managing Business Ethics: Straight Talk About How to do it Right. New York: John Wiley & Sons, 1995.

Paine, L. S., "Managing for Organizational Integrity" Harvard Business Review. 1994 72(Mar-Apr), pp. 106-117.

Clinical Ethics

Jonsen, A. R., Seigler, M., and Winslade, W. J., Clinical Ethics. New York: McGraw-Hill, 1992, 3rd Edition.

La Puma, John, "Clinical Ethics, Mission, and Vision: Practical Wisdom in Health Care" Hospital & Health Services Administration . Fall 1990 (35) pp. 321-326.

La Puma, J., and Schiedermayer, D., Ethics Consultation: A Practical Guide. Boston: James and Bartlett, 1994

Ethics of Care

Gilligan, C., In a Different Voice. Cambridge, MA: Harvard University Press, 1982.

Noddings, N., Caring: A Feminine Approach to Ethics and Moral Education. Berkeley, CA: University of California Press, 1984.

Sherwin, S., No Longer Patient: Feminist Ethics & Health Care. Philadelphia: Temple University Press, 1992

Health Management Ethical Issues

Curtin, L. L., "Why Good People do Bad Things" Nursing Management. 1996 (July) pp. 63-65.

Darr, K., Ethics in Health Services Management. Baltimore, Health Professions Press, 1997. 3rd Edition.

Monagle, J.F., and Thomasma, D.C., (Eds.), Health Care Ethics: Critical Issues. Gaithersburg, MD: Aspen Publishers, 1994

Home Care Ethical Issues

Abel, E., "Ethics Committees in Home Health Agencies" Public Health Nursing. 1990 (7) pp. 256-259

Burger, A. M., et al., "Factors Influencing Ethical Decision Making in the Home Setting" Home Healthcare Nurse . 1992 (10) pp. 16-20

Campbell, L. V., "Physician Marketing: An Ethical Strategy" Caring. 1994 (September) pp. 42-44.

Chubon, S., "Ethical Dilemmas Encountered by Home Care Nurses Caring for Patients with AIDS" Home Healthcare Nurse. 1994 (Sep-Oct) pp. 12-17.

Collopy, B., et al., "The Ethics of Home Care: Autonomy and Accommodation" Hastings Center Report. 1990 20 (2) (Supplement) pp. S1-S16.

Davis, M. C., "The Client’s Right to Self-Determination" Caring. 1992 (June) pp. 17-22.

DeCarlo, M., and Parver, C., "Donning a White Hat: Cast Yourself as the Good Guy with a Corporate Compliance Program" HomeCare . 1997 (October) pp. 85-90

Feldman, C., et al., "Decision Making in Case Management of Home Health Care Patients" Journal of Nursing Administration. 1993 (23) pp. 33-38

Ferrara, P .J., "Expanding Autonomy of the Elderly in Home Health Care Programs" New England Law Review. 1990 (25) pp. 421-455

Fry-Revere, S., et al., Ethics & Answers in Home Health Care: Practical Guidelines for Dealing with Bioethics Issues in Your Organization. Leesburg, VA: George Mason University Center for Health Care Ethics/The Regis Group, Inc., 1996.

Haddad, A. M., and Kapp, M. B., Ethical and Legal Issues in Home Health Care: Case Studies and Analyses Norwalk, CT: Appleton & Lange, 1991

Haase, J., "Mission Possible: Find Out How You Can Implement Value Messages and Missions at Your Company" HomeCare 1997 (May) pp. 38, 136.

Hughes, M. M., "Strategies to Promote Ethical Awareness" Caring 1995 (September) pp. 6-11.

Jenkins, H. M., "Ethical Dimensions of Leadership in Community Health Nursing" Journal of Community Health Nursing. 1989 6 pp. 103-112

Jones, D. H., "Issues & Trends Affecting the Nation’s Hospices" Caring 1997 (November) pp. 14-24.

Kane, R. A., and Caplan, A. L., Ethical Conflicts in the Management of Home Care: The Case Manager’s Dilemma. New York: Springer Publishing, 1993

Kanoti, G. A., "Home Care, a Shifting of Ethical Responsibilities" Cleveland Clinic Quarterly. Fall 1985 (52).

Kristoff, B., et. al., "Patients’ Rights and Ethical Dilemmas in Home Care" Home Healthcare Nurse. 1994 (Sep-Oct) pp. 45-50.

Liaschenko, J., "The Moral Geography of Home Care" ANS. 1994 (17) pp. 16-26

Liaschenko, J., "Home is Different: On Place and Ethics" Home Care Provider. 1996 (February) 1 (1) pp. 49-50.

Mac Millan-Scattergood, D., "Ethical Conflicts in a Prospective Payment Home Health Environment" Nursing Economics. 1986 4 pp. 165-170

Robbins, D., Ethical and Legal Issues in Home Health and Long-Term Care. Gaithersburg, MD: Aspen Publishers, 1996

Robbins, D., "Ethics and Managed Care – A Contradiction" Homecare. 1996 (March) pp. 75-78.

Sabatino, C. P., "Client-rights Regulations and the Autonomy of Home- Care Consumers" Generations. 1990 (14) pp. 21-24

Salladay, S., "Ethics and Home Care" Home Health Review. January-February 1985 (2)

Salladay, S., and Haddad, A. M., "Ethical Issues" in A. M. Haddad (Ed.), High Tech Home Care: A Practical Guide. Rockville, MD: Aspen Publications, 1987. Pp. 169-188.

US Congress, Office of Technology Assessment, Life-Sustaining Technologies and the Elderly, OTA-BA-306. Washington, DC: US Government Printing Office, 1987.

Wicclair, M. R., Ethics and the Elderly. New York: Oxford University Press, 1993