CHAPTER 3 Accountability and the ethical mandate of the health service manager Health care professions, centrally those of medicine and nursing, have helped to give a new prominence to the role of ethics within clinical decision-making. But they are not alone here; all of our health professional programs now incorporate formal ethics or sometimes bioethics within their training programs and colleges insist on these elements in both undergraduate and postgraduate management programs. It would now be odd to find a professional college that did not have or acknowledge a code of ethics, and state governments do precisely the same thing for public sector employees. The prominence of ethics is quite recent, although the nature of ethical practice in all health-related disciplines has always been unavoidably important both for practitioners and recipients of care. To be honest, the recent attention to ethical practice in health care is in part connected with the perception that legal scrutiny of health practice has reached a new intensity; anything that might mollify the situation is therefore worthy of investigation and ethics is pragmatically (and correctly) seen as a component of risk management. It is precisely because health care practice falls within the public ethical domain — the domain of actions, policies and institutions affecting the wellbeing of people through our roles — that people show such astonishment, indignation and outright anger when caregivers starkly fail to live up to social expectations. It is one thing for someone to exploit another’s vulnerabilities; when you think about it for a moment you realise that it is written into the very fabric of competition. But it is quite a different matter when those carrying out the exploitation, often with attendant cruelties, are those whose professional role casts them as responsible for someone’s wellbeing. Feelings of outrage and disgust have recently been given graphic expression in response to the publicising of hitherto hidden cases of sexual and physical abuse of children, many of whom were in the care of churches where nuns, priests and officials were the perpetrators. The magisterial hypocrisy of those who gathered under the banner of ‘suffer little children to come unto me’ leaves most of us seething with indignation. The outcry over the ‘stolen generation’ is another example, although at a higher level of social criticism: government policy and its attendant institutions are the target. The scope of this section is determined by three main assumptions: We can agree that the health service manager’s role involves responsibility for the performance of other people. This fact is key to understanding the ethical dimension of managerial practice, as meeting the requirements of accountability in this role will entail the creation of processes that are transparently designed to meet ethical requirements and are an explicit part of the accountability framework devised for the institution. A nurse or doctor may well ask, ‘is this particular patient’s competently delivered express wish really being honoured here?’ but a manager is charged with a different level of concern and one that relates not to specific outcomes but to processes that facilitate outcomes. Thus, in the case of the patient’s wishes being honoured, the manager’s ethical role is expressed in the creation of processes that support autonomous decision-making within his/her setting. These processes are normally framed in legal terms because they are often directly legislated, but nonetheless their import is ethical and their reality in patients’ lives depends heavily on the creation of effective means of empowerment through processes created and overseen by health care managers.
THE ETHICAL MANDATE OF HEALTH SERVICE PERSONNEL GENERALLY
Reasonable public expectations
FROM THEORY TO ACCOUNTABILITY
Accountability frameworks
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Accountability and the ethical mandate of the health service manager
1. that the health service manager’s role in health care ethics is important, distinctive, and poorly understood;
2. that while there is no shortage of ethics texts, books on bioethics, medical and nursing ethics, moral philosophy journals and journals of clinical ethics, little of it is concerned with the role of the manager in health care;
3. that much of what exercises the general public on bioethical matters is also of personal concern to health managers. For many, of course, the need to be well educated on these matters goes much deeper, as they are responsible for the sites within which ethically charged activities may occur.
