LeadingAge Magazine · September/October 2016 • Volume 06 • Number 05

Seeing Policies and Programs Through an Ethical Lens

September 11, 2016 | by David Tobenkin

Operating ethically in all areas is a priority for providers, but requires an understanding of an organization’s core values among staff, plus the infrastructure to help guide decision making.

Bringing ethical standards and best practices off of wall posters and out of policies and procedures binders and into the actual practices of senior care organizations takes comprehensive and continuing effort, ethicists and LeadingAge members say.

The first step may be gaining an understanding of ethical decision-making itself, which is not necessarily the same as ensuring regulatory and legal compliance, notes Martin Smith, director of clinical ethics at the Cleveland Clinic academic medical center.

“One hopes that regulations and laws have an ethical base to them, but the majority of health care activities are not dictated by regulation,” says Smith, who in January led a LeadingAge Ohio webinar on when providers may wish to seek an ethics consultation by third-party ethics experts. “Ethics tries to help individuals and communities behave and perform their duties in an ethically supportable way. And the messiness of clinical activities can mean that there is sometimes a conflict between the law and best ethical practices, such as, for example, when a person has been designated with a health care power of attorney through a state-authorized document for a patient without capacity but engages in decision-making for secondary gain or makes decisions that the patient or the patient’s family would not have wanted.”

In a 2009 article on ethics and not-for-profit organizations, Stanford University law professors Deborah L. Rhode and Amanda K. Packel noted that long-standing research on ethical challenges developed by psychologist James Rest identifies 4 crucial factors that influence ethical conduct:

  • Moral awareness: recognition that a situation raises ethical issues
  • Moral decision making: determining what course of action is ethically sound
  • Moral intent: identifying which values should take priority in the decision
  • Moral action: following through on ethical decisions

Aging services providers’ ethics initiatives must start by identifying their organizations’ ethical values for the simple reason that adherence to ethical norms is not possible without knowing what the organization stands for, those interviewed say.

At Front Porch, a Southern California provider that serves more than 4,000 residents and 2,000 employees, core values consist of 6 key areas: customer satisfaction; integrity in relationships; individual initiative, expression and creativity; teamwork and trust; fiscal responsibility; and innovative services and products.

“We integrate those into our practices by keeping them at the forefront of all we do,” says Lauren Moulton-Beaudry, Front Porch’s director of ethics and education. “In addition to introducing our core values at new hire orientation, we have had organization-wide trainings, videos, poster and writing contests and community-specific events and initiatives. We have Front Porch Ethics Service representatives at all communities and our home office. We are practitioners and we reference ethical practices and core values on an everyday basis. We need to keep the ethics chatter going. Our Front Porch core values provide a clear moral compass for the organization and all those who serve our residents.”

While ethical issues can be distinct from compliance issues, there is some overlap, notes Karla Dreisbach, vice president of compliance at the Peace Church Compliance Program, administered by the Blue Bell, PA-based Friends Services for the Aging. The program serves more than 70 faith-based, not-for-profit organizations in 14 states by assisting them with the implementation and support of compliance and ethics programs.

“One of the requirements of a compliance program is to have a code of conduct and/or ethics, with the intent of establishing the standards that govern the conduct of those who work in and with the community,” says Dreisbach. “The code of conduct integrates organizational statements of missions, visions and values, and aims to spell out in more detail the expectations of those who work for and with us both from an ethical and regulatory standpoint.”

The behavior and participation of an organization’s leaders is also critical. If leadership does not adhere to its own practices or does not emphasize ethical behavior, the message received by others will be that it is not an organizational priority.

The Front Porch effort is supported through an ethics advisory board that meets 3 times a year and includes managers who help provide leadership to implement key ethics issues, notes Moulton-Beaudry. Those individuals include an outside ethicist and a lawyer; Roberta Jacobsen, Front Porch’s president; a quality assurance director; 2 executive directors; 2 senior vice presidents who lead organizational accountability and organizational advancement for Front Porch; and a Front Porch community resident.

“The board’s purpose is advisory in nature, to make sure that at both the board of directors level and also at the community level we hone our ethic-mindedness,” notes Jacobsen. “It sets the tone for the organization.”

A key best practice is good communication with and between employees and residents, with special attention toward listening to the preferences of community members.

“Ethics is about honoring our residents’ choices,” Moulton-Beaudry says. “We have guidelines, tools and training techniques for ethical decision-making and advanced directives. We are working with a diverse group of people. We might assume that we all feel the same way about things but that is not the case. That’s why it’s important to know our residents.”

One way to elevate the use of ethical processes is to maintain a specific ethics services department within an organization. At Front Porch, the Ethics Service is charged with integration and maintaining focus and supporting staff in making ethical decisions.

“One of the factors that distinguishes us … is that we have a wholly dedicated ethics service in addition to compliance,” says Moulton-Beaudry. “Everyone has compliance and sometimes ethics and compliance get meshed together. Compliance asks, ‘Can we do this?’ An ethics service takes the time to ask whether we should be doing it. That carries through our philosophy of taking ethics issues very seriously.”

In addition to its ethics board, the organization has 2 regional ethics committees in its northern and southern regions that help implement ethical practices throughout the organization. The committees meet 4 times per year and are comprised of diverse staff from a wide range of departments.

Committee members organize recommendations into practical steps. “We hone our ethical mindedness and work through the ethical decision-making process,” Moulton-Beaudry says. “One of the things the committees did as a catalyst was to group read, [psychologist Piero Ferrucci’s The Power of Kindness: The Unexpected Benefits of Leading a Compassionate Life] and apply those principles in our meetings. We engaged with the issues the book raised and how they could affect our service.”

New ethical issues continue to emerge, as new legal or regulatory requirements are introduced. The California End of Life Option Act, a new state law that took effect in June 2016 that allows physicians to assist certain terminally ill individuals with dying through the prescription of medicines that will hasten death, has significant implications for conduct by Front Porch staff and is currently being analyzed, Jacobsen says. “Our ethics board and outside counsel are taking the lead in examining the requirements of that law with respect to our potential involvement in its implementation, including how to ethically respect the rights of residents and staff who may be involved in that process. So there is an ethical process and overlay to the law.”

For more on ethics in aging services, see the LeadingAge Ethics Toolkit, with links to a variety of resources.