Sunteți pe pagina 1din 28

HASTINGS CENTER REPORT

SPECIAL SUPPLEMENT
July-August 2002

ETHICS AND
TRUSTEESHIP
FOR HEALTH CARE

Hospital Board Service


in Turbulent Times

B RUCE J ENNINGS
B RADFORD H. G RAY
V IRGINIA A. S HARPE
L INDA W EISS
AND A LAN R. F LEISCHMAN
H ospitals are complex and imposing institutions. They are
vital to the communities they serve and to society as a
whole. They are places of joy and sorrow, rescue and loss,
recovery and death. They command enormous capital in-
vestment, expensive high technology, and often the largest
payrolls of any organization in their community. They are
monuments to governmental and philanthropic largess.
Most are now integrated health systems offering multiple
health services and countless activities under the headings
of counseling, education, health promotion, and commu-
nity service. They employ and support the practice of some
Table of Contents of the most highly trained, intelligent, and capable profes-
sionals in the nation; their hallways are thick with titles,
The Hospital Trustee Today • S6 academic honors, and advanced degrees.
The Ethics of Hospital Trusteeship • S13 Over half of the nation’s hospitals today are not-for-
Trustee Ethics in Practice • S16 profit organizations, traditionally called “voluntary” be-
Hard Choices • S20 cause, while they are managed by specialized professionals,
Carrying on with the Conversation • S22 they are governed and supported by volunteers—philan-
References • S23 thropists, community leaders, business people, clergy, and
others with a civic orientation of service. These are not-for-
An Overview of the Project • S8 profit hospital trustees, men and women who serve with-
A Model Workshop on Ethical Issues in • S25 out pay and who are entrusted with the oversight, mission,
Not-for-Profit Hospital Trusteeship and strategic operations of these expensive and vital insti-
Task Force Members • S27 tutions.1
It is important to all of us that not-for-profit hospitals
be governed well and trustees do their job well. Hospitals
deal with the most fundamental matters of human well-
being; their services are not just another commodity in the
Bruce Jennings • Senior Research Scholar marketplace. By providing health care services of high qual-
The Hastings Center ity, a hospital is an important community resource. Those
Bradford H. Gray • Director
who run not-for-profit organizations owe a fiduciary duty
Division of Health and Science Policy
to the founders, benefactors, and donors who support the
The New York Academy of Medicine
institution with an expectation that their money will be
used in certain ways and for certain purposes. Not-for-
Virginia A. Sharpe • Associate profit hospitals also enjoy tax exempt status in return for
The Hastings Center fulfilling certain public purposes, and thus those who gov-
Linda Weiss • Senior Program Officer ern these institutions have a responsibility to all citizens
Division of Health and Science Policy and taxpayers to ensure that these public purposes are real-
The New York Academy of Medicine ized. There is much with which trustees have been entrust-
Alan R. Fleischman • Senior Vice President
ed. These public and private fiduciary promises, implicit in
The New York Academy of Medicine
each trustee’s acceptance of appointment to the board, lay
the foundation for a set of more specific ethical and legal
duties that not-for-profit hospital trustees assume.
On the cover: Hospital Lobby, Tulane
University Hospital, by May H. Lesser,
©1989 Tulane University Medical Center
Bruce Jennings, Bradford H. Gray, Virginia A. Sharpe, Linda Weiss, and Alan
R. Fleischman, “Ethics and Trusteeship for Health Care: Hospital Board Ser-
vice in Turbulent Times,” Hastings Center Report Special Supplement 32, no. 4
(2002): S1-S28.

S2 July-August 2002/HASTINGS CENTER REPORT


This report is a discussion of the can hospital is a history of transfor- (and in some cases potential buyers)
roles and responsibilities of those mation and adjustment to shifting for not-for-profit hospitals.7
who serve on not-for-profit hospital conditions of science, economics, Each of these factors, and others,
boards. It is about the ethics of being and social mores.5 Yet in the last calls for new ways of thinking and
a trustee.2 It is about how ethics can twenty years, American not-for-prof- managing among hospital executives
be used to assist, facilitate, and en- it hospitals have been challenged by and for new perspectives and talents
able already virtuous people to make an unusual convergence of forces. among trustees. This changing envi-
hard choices. It is not about one right Changes in medical science and prac- ronment manifests itself differently
answer but about striving to do the tice have changed the way hospitals in different regions, states, and com-
right thing for the right reasons. are used and function in the health munities. Overall, the developments
In a legal sense, not-for-profit care system, with marked trends to- of the past twenty years have made
trustees are not as highly regulated or ward shorter lengths of stay. Changes the job of trustee ethically harder.
as accountable as the directors of for- in large-scale public and private The legal duties of care, obedience,
profit corporations, who are formally health care financing systems, in par- and loyalty provide only the begin-
accountable to the shareholders who ticular toward prospective payment nings of a framework with which to
elect them. State attorneys general arrangements and contractually ne- analyze the trustee’s ethical responsi-
oversee the conduct of not-for-profit gotiated prices, have put new pres- bilities. Consider the following sce-
trustees, and they rarely use their reg- sures for efficiency and cost-contain- narios, which are derived from our
ulatory power to interfere with board ment on many hospitals, and placed interviews with trustees:
actions, except in cases of the most them in a more competitive environ-
blatant misconduct and abuse of ment than before.6 Managed care s To sell or not to sell?
trust.3 The law trusts trustees and systems have put hospitals into new Mergers involving major competing
provides a set of general guidelines relationships with physicians. Finally, hospitals led the trustees of Metro-
for conscientious service. The legal the presence of for-profit hospitals politan Hospital to hire a consultant
obligations of hospital trustees can be owned by investor-owned companies to do an environmental scan and ad-
summarized as a duty of care, a duty has presented competitive challenges vise the board about strategic alterna-
of obedience, and a duty of loyalty.4
The trustee must attend meetings
and become informed enough to Cover illustration, Hospital Management, February 1920.
make reasonable, prudent decisions.
A trustee must adhere to the mission
of the hospital. A trustee must pursue
the best interest of the hospital and
not misuse his or her position to ad-
vance personal interests. The trustee
must avoid conflicts of interest, en-
gage in open decisionmaking, and
act with an independent mind and in
a fiduciary spirit.
This emphasis in the law of trusts
and trusteeship on personal, consci-
entious goodwill and ethical motiva-
tion comports well with the perspec-
tive of ethics. Together, legal and eth-
ical traditions provide guidance and
high expectations for trustees.
Trustees must face many dilemmas
and hard decisions in the governance
of a hospital. Yet they do not face
those tough choices without a tradi-
tion of values and purposes to guide
them. The ethical heritage of hospital
trusteeship is an anchor in troubled
waters.
Turbulent times are not new for
hospitals. The history of the Ameri-

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S3
tives. Although the hospital was tive officer presented these facts to the After a financial crisis that elicited
showing a positive bottom line, the board and told them of his decision intervention from the state, a new
trustees were worried because the hos- not to tell the deceased patient’s fami- CEO was brought in to revive the
pital’s once middle-class neighbor- ly about the discovery of the empty hospital by improving relations with
hood had changed and the hospital vial. and service to the community and by
was increasingly subsidizing the care strengthening the medical staff. He
of a substantial uninsured population s Allocation of scarce financial began by recommending diversifying
through revenues generated from resources. the board and enticing new physi-
other sources, including the hospital’s The end-of-year financial report cians to the staff. The doctors who
endowment and some declining char- showed that the hospital had lost could be attracted, however, were not
itable support. money for the first time in anyone’s necessarily of high quality, and at-
The consultant reported that man- memory, and the board asked the tracting them proved to be expensive,
aged care was causing hospitals to CEO for an explanation and a plan of particularly for a financially distressed
rapidly reduce prices for a shrinking action. She was made to understand hospital that was laying off low-in-
pool of insured patients. He believed that her job was on the line. come employees and was already un-
that the hospital would face ever- In her report at the next meeting, able to provide programs and services
growing losses within the next three she reported that reducing costs was that the board saw as necessary. Ex-
to five years. Mergers with the local more feasible than increasing revenue, pending resources to attract marginal
not-for-profit systems were discussed, since the hospital’s occupancy was de- doctors while laying off conscientious
but none of those systems was inter- clining. The most reasonable cost-re- employees struck some trustees as a
ested in expanding into Metropoli- ducing alternatives were all unappeal- dubious tradeoff, but they found al-
tan’s neighborhood. The consultant ing—to defer maintenance on the ternatives in short supply.
believed, however, that a for-profit building, to reduce patient care
company that was seeking entry into staffing levels (perhaps jeopardizing s Closing a facility.
their market area might purchase the quality and creating labor relations Hillview Medical Center is the prod-
hospital. problems), or to close some outpa- uct of a hospital merger that was in-
After much discussion, the board tient clinics that were losing a lot of tended to ameliorate the financial dif-
concluded that the dilemma they money because they were the main ficulties of two hospitals but instead
faced was between using their charita- source of care for the community’s exacerbated them. Five years after the
ble assets to provide hospital services uninsured population. merger took place, the medical center
until those assets were exhausted, and She recommended closing the was losing millions of dollars each
selling the hospital and putting the re- clinics, since the benefits of doing so year. Hillview’s uptown facility was lo-
sulting funds (along with the hospi- would be felt throughout the institu- cated in a low-income community,
tal’s endowment) into a grant-making tion, just as would the costs of keep- with no other acute care hospitals
foundation that could address com- ing them open. The board argued nearby. The physical plant was anti-
munity needs. They disagreed about about whether the care provided at quated and inefficient and needed sig-
whether they could responsibly aban- those clinics was an essential part of nificant capital investments to stay
don their hospital’s historical mission the hospital’s mission or whether it fully functioning. Financially, the
so long as they were capable of pursu- was an activity that they could no soundest option was to close the up-
ing it. longer afford. town campus. Some trustees saw this
as a betrayal of the institution’s com-
s Responding to medical error. s Serving a changing community. munity service mission, and commu-
A patient died unexpectedly in the Eastlake Hospital is located in a sub- nity members advocated strongly for
hospital after a routine examination urban community that over the last keeping the facility open. Some
and treatment in the emergency twenty years shifted from middle-in- trustees felt they should be responsive
room. When her body was removed come white to working class African- to community wishes and needs,
from the treatment room, an empty American. The hospital, with a self- while others felt that keeping the up-
medication vial was discovered in the perpetuating board that served with- town facility open would jeopardize
bed, and it was thought that adminis- out term limits, never added new the survival of the institution as a
tration of the wrong medication members in response to the shift in whole.
might have contributed to the pa- the population and ignored the
tient’s death. Post-mortem tests reas- changing needs of its surrounding s Conversion from not-for-profit to
sured the hospital’s medical director community, whose members increas- for-profit status.
that this was not the case, and the ingly used hospitals in adjacent sub- Valley Hospital had a long history as a
county medical examiner chose not to urbs. community hospital, but health sys-
investigate. The hospital’s chief execu- tem change combined with debt from

S4 July-August 2002/HASTINGS CENTER REPORT


a major renovation a decade ago left tionships with one another. Ethics course of action, the decisionmaker is
the hospital in increasingly bad finan- provides standards and rules for con- challenged to articulate more than
cial condition. The practices of many duct; it interprets and clarifies funda- just a visceral feeling or a simple fi-
of its physicians had been purchased mental values, virtues, and principles nancial analysis. The decision must
by a not-for-profit health system that have proven themselves over the be supported with clear and cogent
based in the nearby city, and the re- centuries to be reasonable and benefi- arguments consistent with institu-
maining doctors competed vigorous- cial to humankind. tional and personal goals and values.
ly with doctors in adjacent towns that This is generally how philosophers To focus on trustees as individuals
had their own hospitals. With a crisis view ethics. In ordinary usage, the is to identify only one side of the sub-
looming regarding interest payments terms “ethics” and “ethical issue” ject of trustee ethics. The most im-
on the debt, and after meeting with often carry negative connotations. portant decisions that trustees make
several consultants, the board con- They conjure up images of scandal, are not made alone, but collectively,
cluded that the hospital’s existence as abuse of power and office, miscon- by boards of trustees acting in a cor-
an independent institution would duct, and the like. But scandal and porate capacity. Trustee ethics there-
have to end. After soliciting and eval- wrongdoing are not the topics with fore requires attention both to indi-
uating a handful of offers regarding which to begin a productive conver- viduals who occupy the role and dis-
merger and purchase, the board nar- sation about hospital trustee ethics. charge the responsibilities of that role
rowed its options to two: to merge We want to promote ethical analysis and to the way these individuals op-
with a neighboring not-for-profit of the world of trustees because we erate collectively as governing boards.
hospital or to sell to a national in- believe it is encouraging and helpful Properly organized and functioning,
vestor-owned hospital company, cre-
ating a grant-making foundation In ordinary usage, the terms “ethics” and “ethical issue”
with the proceeds.
From a financial point of view, the conjure up images of scandal, abuse of power, and the like.
sale option was preferable, and it was
believed that the size of the invest- But scandal and wrongdoing are not the topics with which
ment would ensure the purchaser’s
commitment to maintaining the hos- to begin a productive conversation about hospital trustee
pital and keeping it open. The med-
ical staff and hospital employees also ethics. We want to promote ethical analysis of the world of
endorsed the sale option, mistrusting
the neighboring hospital (and its doc- trustees because we believe it is encouraging and helpful
tors) and fearing that they would
close Valley down if given the to trustees, not threatening.
chance—a fear shared by many
trustees. At a public meeting, howev-
er, the most vocal community mem- to trustees, not threatening. From a board can enable trustees together
bers spoke strongly against the for- time to time, scandals do occur and to accomplish things that no one
profit sale, and some trustees felt that must be dealt with in not-for-profit trustee acting alone could hope to ac-
the board should respect the commu- institutions and hospitals, but they complish, and that no mere collec-
nity’s preferences. are not what we address in this re- tion of individuals, if they were not
port. properly organized, could accom-
s s s Ethics is the study of how to make plish.
hard choices in the face of conflicting It follows that paying attention to

W hy bring an ethical perspective


to bear on the conduct of
trustees? To be entrusted with the
values. It offers a rational approach to
making better judgments and solving
real problems. Ethical arguments are
how boards are organized and func-
tion, and how trustees make collec-
tive decisions, is of the utmost impor-
governance authority of a modern grounded in principles, contracts, or tance. If hospital governance is to ful-
hospital is to be placed in a position foreseeable consequences. Principles fill high standards of ethical conduct
of significant power and responsibili- are rules that guide actions; contracts and to honor the trust that has been
ty. The study of ethics has to do with are promises of future actions; and placed in it, then it is not enough to
how such power should be used, how consequences are the risks and bene- appeal to the ethical standards and
human beings should live together fits that may be arrayed to guide ac- conscience of individual trustees
for mutual assistance and mutual ad- tions in order to result in the most alone. For even conscientious indi-
vantage, and the boundaries people benefit and the least harm. When viduals may find it difficult or impos-
should not transgress in their rela- making an ethical argument about a sible to perform well in an unsup-

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S5
portive environment. It is also neces- but we do not—and could not—dic- ciated with the trustee’s role by law,
sary to examine how boards should tate exactly how they must act to custom, and tradition. We have
function so that individual trustees meet that standard. found that our recommended princi-
can be and do what they should. A study of trustee ethics should ples are very similar in substance to
Although trusteeship is not strictly start by examining the power and au- those already widely accepted in the
speaking a profession—indeed, it is thority of trustees. In general, special trustee world, although the terminol-
one of the most significant bastions power entails special moral responsi- ogy we use may be unfamiliar, and
of civic volunteerism and amateurism bilities, and this is no less true for the way we apply these principles in
remaining in our highly specialized trustees than for other professions, practice may offer new food for
society—the ethics of the hospital occupations, or significant social thought to many in the field.
trustee has an affinity in many im- roles. Conversely, if the powers and Third, in light of these general
portant ways with the ethics of pro- authority of trustees are ambiguous, principles, we turned our attention to
fessionals’ roles. A “role” is a set of shifting, and inconsistently applied, practice and sought to offer more
norms, social expectations, and values that can be a recipe for irresponsible specific guidance and commentary
as well as a set of particular skills, conduct and a lack of ethical ac- about the actions of trustees in sever-
functions, and competencies. countability. al different kinds of situations, and
We analyze how trustees ought to Through the work of our project about the internal workings of the
act, without losing sight of the actual task force, staff research, and our in- board and governance system in the
constraints and circumstances that af- terview study with trustees and hos- hospital. If the board’s systems and
fect their actions in the real world. pital executives, we have sought first processes are working poorly, individ-
Our aim is to be prescriptive, but to define and specify the interests and ual trustees will find it hard to be re-
only at a level of generality that is needs served by the trustee in a not- sponsible and effective.
compatible with the actual variety for-profit institution and to explain Armed with a sense of the trustee’s
and diversity of boards, hospitals, the nature of the power, authority, power and the interests that are at
communities, and cases. There is no and expertise invested in the trustee stake, it is possible to construct a
single best way to govern a hospital, role. This includes an appreciation of framework of ethical principles that
and there is no single right way to be the human as well as the financial in- flow from the role, the functions, and
a trustee. For this reason we have terests involved, the special moral sig- the cultural expectations that define
chosen to speak at length about gen- nificance of health care services, and the trustee in our society.
eral principles, and less about specific the special social functions and im- In the past, trustee ethics have
duties or specific actions trustees portance of not-for-profit organiza- been largely tacit. But these tacit un-
ought to perform. Principles are like tions in health care. derstandings are being unraveled by
large area maps. They tell you the di- Second, reasoning from the power the current health care marketplace
rection you must go to reach your and interests inherent in trusteeship, and cannot be taken for granted. In-
destination, but they do not show all we have formulated ethical principles sofar as this trend cannot be simply
the roads you might follow. Several that should (and often implicitly do) reversed, it is all the more necessary
paths could lead to where principles govern the conduct of those individu- to re-establish and revivify a sense of
tell you to go. So it is with our dis- als who occupy that role. These pre- ethical mission and obligation for
cussion here. We aim to challenge scriptive principles can be compared hospital trustees on an explicit ethical
trustees with a high ethical standard, with the responsibilities that are asso- footing.

THE HOSPITAL TRUSTEE TODAY

P rivate, not-for-profit organiza-


tions are the predominant form
through which hospital services have
ment to the community. Through
these institutions, society attempts to
meet the needs of those in the com-
those responsible for decisionmaking.
Cost containment and efficiency have
become more pressing concerns, and
been provided in the United States. munity and in special populations hospitals have experienced enormous
Deeply embedded in the geographic who are unlikely to receive effective organizational change involving
and cultural community, and with care through for-profit health care de- mergers, joint ventures, creation of
historical roots in religious and other livery.8 for-profit subsidiaries, acquisitions,
philanthropic institutions, not-for- In recent decades, the economic network development, and conver-
profit hospitals seek to promote social values of the marketplace have be- sion from not-for-profit to for-profit
welfare and public good through civic come increasingly prominent in the status through sales or reorganization.
betterment and long-term commit- hospital industry and the minds of The not-for-profit hospital still pre-

S6 July-August 2002/HASTINGS CENTER REPORT


dominates among American hospitals
and will likely continue to play a cen- In virtually every case, we were told about efforts either to
tral and vital role in the American
health care system for the foreseeable assure the hospital’s continued presence in the
future.9 But commentators are asking
questions about what makes not-for- community, the continuation of key aspects of the
profit hospitals distinctive and about
the nature of their community oblig- hospital’s mission, or the continuation of the board’s voice
ations as tax exempt organizations. As
market-driven but charitable organi- after the transaction was completed.
zations, hospitals face difficult con-
flicting pressures that ultimately must
be faced by their boards.10 sustaining treatment as a governance trustees and hospital CEOs about
or policy issue.)11 their experiences and perceptions at a
Pressures in the Health Care These factors suggest that the gov- sample of fifteen hospitals in the
Environment ernance structures of not-for-profit greater New York area and six hospi-
hospitals face several challenges, in- tals elsewhere that had considered

I n the past, boards of trustees fo-


cused primarily on selecting hospi-
tal executives and on fundraising.
cluding difficult resource allocation
decisions and perhaps even more dif-
ficult structural and control deci-
sale or conversion to a for-profit.12
When asked to describe trustees’
responsibilities at their institution,
Now, trustees of not-for-profit hospi- sions—concerning mergers, acquisi- our respondents provided a varied list
tals are being asked to make critical tions, closure, sale to other institu- regarding oversight, policymaking,
decisions that relate to their institu- tions (for-profit or not-for-profit), or board-CEO relations, and mission.
tion’s core values, and sometimes to reorganization to serve a new mis- The most common responses per-
its very existence. In recent decades sion. How well prepared are boards tained to financial oversight, meeting
there have been several developments to deal with such crucial issues? What community needs, assuring quality of
of great importance to the gover- tools have they to work with? Boards care, selecting and monitoring the
nance structure. are collections of powerful and im- performance of the CEO, assuring
First, investor-owned hospital portant people who are generally adherence to mission, policymaking,
companies have entered the field, honest and concerned about their in- and, more rarely, fundraising and ad-
demonstrating that hospitals can be stitutions. But have they the time to vocacy for the institution. Almost no
run profitably, bringing new operat- reflect on their duties and responsi- trustees used the language of ethics to
ing styles and methods, and raising bilities and on the values that ought describe their responsibilities, al-
doubts about the justification of state to underlie critical decisions? What though ethical issues were implicit in
tax exemptions for not-for-profit en- do trustees think of these questions: many of their responses—particularly
tities. These companies have also be- those pertaining to mission and com-
• What are the responsibilities and
come potential purchasers of not-for- munity needs.
duties of a not-for-profit hospital
profit hospitals. In addition, cost- Ethical issues were closer to the
trustee?
containment in federal programs and surface when we asked trustees to
the rise of managed care on the pri- identify the major issues that had en-
• What values ought to be consid-
vate side have introduced pressures gaged their board over the previous
ered in board deliberations?
that threaten the ability of hospitals year and to describe the considera-
to pursue mission-related activities tions that had been involved. The is-
• How can trustees address and re-
that are subsidized by revenues from sues fell into eight broad categories,
solve conflicts among their duties?
paying patients. Moreover, an over- presented here in order of frequency.
supply of beds in some areas and re- The categories inevitably overlap to
• How can trustees continue to
duced lengths of stay have led to con- some extent.
promote the commitment of the
cerns about the economic viability of Institutional autonomy. Most of
not-for-profit hospital to social
some hospitals. Finally, hospitals have the boards at our sample of hospitals
welfare and public good?
become the site of many complex had dealt with questions regarding a
moral choices involving life, death, merger affiliation with, or a sale to,
and health care decisionmaking. (In- Hospital Trustee Survey another hospital or hospital system.
terestingly, most of the trustees we in- Findings Many different arrangements had
terviewed did not at first blush view been considered. In virtually every
medical decisionmaking about life-
W e explored these matters in in-
terviews with ninety-eight
case, however, we were told about ef-
forts either to assure the hospital’s

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S7
continued presence in the communi- Mart of health care,” reducing quali- city hospitals,” “becoming a signifi-
ty, the continuation of key aspects of ty, closing a clinic on which poor cant provider in the Northeast U.S.,”
the hospital’s mission, or the continu- people depended. As one chair put it, shifting toward ambulatory care, be-
ation of the board’s voice after the whereas a business can “look at the coming more flexible and responsive
transaction was completed. Virtually bottom line of every department and to health system change.
no one described his or her board’s say ‘Get rid of everything that loses Facility enhancement. For many
primary goal in revenue maximizing money,’ we have to remind ourselves institutions—more than one third of
terms. that we have a mission, a Catholic the New York sample—questions
Financial issues. Financial issues mission, that has to be fulfilled.” about enhancing or altering facilities
were prominent considerations for Positioning the hospital. In addi- had been major board issues in the
our conversion sample, and for a ma- tion to issues involved with mergers previous year. These issues were al-
jority of institutions in the New York and sales, almost half of the New most always presented in terms of en-
area sample, financial issues had been York area sample mentioned that hancing quality, meeting unmet
among the two most important in their board had dealt with funda- needs, and finding the needed capi-
the previous year. In virtually every mental issues regarding how the hos- tal. The decisions could be very diffi-
case, the key problem was the need to pital should respond to turbulence in cult. A trustee at a financially strug-
reduce costs. Our respondents almost the health system. Issues mentioned gling institution described the op-
always identified tradeoffs that the were mostly described in rather gen- tions underlying the board’s decision
board had been reluctant to make— eral terms: “getting our hands around to spend $3 million on MRI equip-
laying off staff in their low-income managed care,” responding to com- ment. The expense “would probably
neighborhood, “becoming the K- petition from the networks of “big bankrupt the hospital, but not buy-

representatives of leading professional associations repre-


An senting hospitals and hospital leadership.
The task force met six times over two years to discuss
Overview Tously
aking trustee ethics seri-
and debate the current state of hospital governance, the
pressures that not-for-profit hospital trustees face, and
of the
does not require that
the hard choices they must often make. The task force
all trustees always agree.
also considered the values, cultural expectations, and his-
Project
There is room within the
torical traditions that inform the trustee role as back-
scope of conscientious, ethi-
ground for developing a typology of ethical issues in
cal board service for a broad
hospital trusteeship and a set of principles and norms to
range of disagreement over
address them.
many financial, institutional, and public policy issues
In September 1999 a final public meeting, attended
that affect hospital operations today. Nonetheless, pre-
by trustees and other interested persons from hospitals in
cisely because of the conflicting forces that buffet
the New York metropolitan area, was held at the New
trustees, many are seeking to give their debates and pol-
York Academy of Medicine. The work of the Task Force
icy disputes some ethical context and perspective.
was presented at that conference and a model education-
It was with this goal in mind that The Hastings Cen-
al workshop designed for trustees was tested on a pilot
ter and The New York Academy of Medicine began in
basis.
1997 a two-year research project on the ethical responsi-
The report presented in these pages grows out of the
bilities of not-for-profit hospital trustees. The project
project’s work. It draws on the findings of the interview
was supported by the Greenwall Foundation.
study and the deliberations of the task force, together
Our research was built around two activities. We con-
with other research conducted by project staff. While the
ducted a series of lengthy in-person interviews with
arguments made and the views expressed in this paper
ninety-eight trustees and chief executive officers from fif-
are those of the authors, we have tried to adhere to what
teen not-for-profit hospitals of different sizes and types
we understood to be the recommendations, conclusions,
located in the greater New York metropolitan area. We
and thinking of the members of the task force. Their
also convened a project task force chaired by Dr.
lively debate and broad-ranging expertise and experience
William Hubbard, former dean of the University of
created a stimulating setting that generated not only this
Michigan School of Medicine and former chief executive
report, but also a collection of commissioned papers that
officer of Upjohn, and comprised of hospital trustees,
were presented to the task force and will be published
executives, physicians, philosophers, social scientists, and
during the coming year.

S8 July-August 2002/HASTINGS CENTER REPORT


ing it would certainly bankrupt the pital functioning during a labor dis- Trustees’ Views on Ethical
hospital, because doctors would not pute. Issues
want to work here. So, we are buying Quality of services. A handful of
it.”
Physician relations. Managing the
hospital’s relationships with physi-
interview respondents mentioned
quality as a major issue of the previ-
ous year, either in vague terms
A lthough there are clearly con-
flicting value dimensions in-
volved in many issues with which
cians is another common problem (“monitoring quality”) or concretely trustees are dealing, few trustees that
with which trustees must grapple. Is- (using an accreditation visit to im- we interviewed think of themselves as
sues include responding to physician- prove quality, seeking ways to im- being engaged in ethical decision-
related quality problems, deciding prove patient satisfaction, or getting making. Indeed, when asked early in
whether requested investments the board more meaningfully in- our interviews whether their board
would benefit primarily the doctors, volved with quality, for example). had dealt in the past year or so with
making tradeoffs between expendi- Community role. Issues men- any matters that they think of as eth-
tures and the risk that doctors would tioned here included deciding ical issues, their typical initial re-
take patients elsewhere, and arguing whether and how to help a neighbor- sponse was a very long pause. Re-
about fairness in hospital-physician ing hospital that was in trouble and sponses thereafter ranged from a
joint ventures. considering “how to bring together handful of comments that the board
Managerial issues. Issues men- all the diverse interests—doctors, had encountered no ethical issues to a
tioned here included strengthening communities, and the board—to handful that every board decision
the management team, improving work together” to meet community had an ethical component. Some
the board itself, and keeping the hos- needs. trustees assumed that we were talking

Our goal in this report is to show that the decisions trum of different working arrangements that permit
made by hospital trustees and the actions of hospital board members and executives to fulfill their functions
boards raise important ethical issues and that the ethical responsibly and to discharge the ethical obligations of
dimensions of trustee service should be more explicitly their respective roles. The vision of ethics we offer here
recognized and discussed. We hope to provoke and to calls for a thoughtful, well-informed trustee, one who is
contribute to such a discussion and to facilitate an ongo- not intrusive or overbearing in dealing with manage-
ing interest in the topic of trustee ethics, both within the ment, but who works as an effective partner with man-
trustee community and in the broader discussion of agement and strives to exercise the board’s responsibili-
medicine and health care in our society today. We aim in ties effectively and with sound reasoning and judgment.
particular to clarify the ethical concepts and principles Careful discussion of ethics among trustees can assist in
pertinent to the activities of both individual trustees and that regard, and in this way will also be beneficial to hos-
boards. pital management.
These concepts and principles do not arise in a his- We would like to thank Dr. Hubbard for his steady
torical or cultural vacuum; the “practice” of trusteeship hand as chair of the task force and for his invaluable ad-
has a history and a tradition. It has a social meaning and vice and support. We also wish to acknowledge grateful-
normative rules. It can be done well or badly, responsibly ly the support and encouragement provided by William
or irresponsibly, beneficially or harmfully, conscientious- Stubing and the Greenwall Foundation. Strachan Don-
ly or carelessly. Being a hospital trustee is a voluntary ser- nelley of The Hastings Center had the original idea for a
vice with heavy demands, and persons who give of their collaboration between Hastings and The New York
time and talents in this service should be esteemed. It is Academy of Medicine, and Dr. Jeremiah Barondess,
also a service that should never be undertaken lightly or president of the Academy, has been very supportive of
in a pro forma manner. Organizations, including hospi- the project.
tals, sometimes find it difficult to recruit qualified candi- Many colleagues on the staffs of our respective insti-
dates to serve on their boards. But the importance and tutions provided help on the project and in the prepara-
responsibilities of this role should never be underesti- tion of this report. We would like to thank from The
mated. Hastings Center Ashby Sharpe, co-author of this report,
Some may worry that raising trustees’ awareness ethi- Rita Strobel, Marna Howarth, Chris McKee, Marion
cal issues will lead them to seek more influence in the Leyds, and Ellen McAvoy; and from the Academy our
governance of their organizations at the expense of man- co-authors and colleagues, Bradford Gray and Linda
agement. Again, the ethical perspective we offer does not Weiss.
stipulate any particular style or arrangement in the gov- —Bruce Jennings and Alan R. Fleischman
ernance and management of hospitals. There is a spec- Project Co-directors

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S9
about conflicts of interest among • trying to represent fairly the hos- of the hospital, fraud and abuse con-
trustees, which had been a significant pital’s different constituencies cerns in contracting arrangements be-
problem in a few institutions. (medical staff, employees, and the tween the hospital and physicians,
Some trustees mentioned patient- populations of different commu- credentialing and quality issues, and
related bioethical issues about which nities served by the hospital) re- how physicians handle cases with
the board had been briefed, such as gardless of the trustee’s own bias or poor outcomes.
hospital policies regarding end of life connections, Clearly a wide variety of issues
decisions. In mentioning these topics, come to mind when trustees and
respondents generally indicated that • deciding whether to close facili- CEOs are asked about ethical issues
their institution had policies and ties that were losing money or in with which their board has grappled.
mechanisms for dealing with bioethi- need of major capital infusions, Most of these issues are quite differ-
cal issues, and few indicated that their ent from those that have traditionally
institution treated bioethical issues in • deciding whether to sell the hos- engaged the field of bioethics. And
patient care as one of the board’s di- pital to a for-profit purchaser, and although some are similar to those of
rect concerns. Catholic hospitals were ordinary business ethics, many flow
an exception, particularly if they had • making resource allocation deci- from hospitals’ responsibilities either
been thinking about mergers. sions, either in ordinary situations as patient care organizations or as
A significant minority of our re- or regarding the use of proceeds not-for-profit organizations.
spondents mentioned issues pertain- from selling the hospital.
ing to mission, or tensions between Issues and Ambiguities in the
mission and business considerations, Another group of value-laden is- Trustee Role
when asked about whether their sues identified by respondents in our
board had dealt with ethical issues.
These issues mostly pertained to fi-
nancing money-losing services or
survey were presented solely as busi-
ness issues. Examples included: I n our interviews with trustees and
CEOs, several difficult issues sur-
faced regarding different aspects or
• the dangers to the institution of
meeting community needs, often in dimensions of the trustees’ role.
taking on additional debt,
the context of possible mergers, sales, Again, our topics overlap to some ex-
or affiliations. tent.
• how the admissions office in a
Examples of mission-related issues Trustees as representatives. Un-
rehabilitation facility should han-
that the trustees and CEOs identified like members of political bodies, cor-
dle patients who arrive without a
as “ethical” included: porate boards, or boards of member-
proper referral from a physician,
ship organizations, hospital trustees
• deciding whether to stay in the
are generally not elected or responsi-
city or re-locate the hospital, • how to handle downsizing and
ble to specific constituencies who
layoffs,
elected them. Most of the trustees we
• deciding whether to invest in or
interviewed had been appointed by
maintain unprofitable specialized • the extent of salary differences
their own board and did not view
services to meet community from top to bottom of the institu-
themselves as the representative of
needs, tion, and
any particular interest. They said ei-
ther that they did not see themselves
• deciding whether to help a strug- • issues regarding the corporate
as serving in a representative capacity
gling health care institution near- compliance program.
at all or that they represented the en-
by,
A third set of responses pertained tire community. Some spoke of the
to medical staff issues—a doctor with trustee role as mediating among the
• deciding whether to permit two
a drug problem, unspecified “unethi- conflicting interests of the hospital’s
standards of care—for the rich and
cal behavior” by a physician, prob- different stakeholders—patients,
poor—within the hospital,
lems with physicians who have lost management, doctors, nurses, other
their licenses, issues in disciplining employees, and the community at
• ensuring that the hospital does
and occasionally removing a doctor large.13
not turn away patients in need,
from the staff, misbehavior by “doc- We encountered three issues re-
tors” in the performance of their garding the “representative” role of
• coping with tensions between
duty, dealing with a “very con- trustees. The first arose when a board
commitment to the hospital versus
tentious doctor” who the CEO feared decided that in recruiting and select-
commitment to the community in
would physically attack him, dealing ing new members it should seek to
trying to assure the institution’s fi-
with a staff member who had en- reflect the ethnic composition of the
nancial soundness,
gaged in fraudulent behavior outside population served by the hospital.

S10 July-August 2002/HASTINGS CENTER REPORT


Walk-in Clinic
by May H. Lesser, ©1989 Tulane
University Medical Center

This raised the question whether There is an expectation, established by tradition and as a
these new trustees ideally speak for
the population that they “represent.” condition of federal tax exempt status, that
Several women and minority-group
trustees whom we interviewed ob- not-for-profit hospitals engage in “community benefit”
jected to being viewed as “speaking
for” the groups from which they were activities—care for the uninsured, involvement in
drawn, even as some of them ob-
served that their own presence on the educational and research activities, assessment of
board was making it more sensitive to
those very groups. community needs, and collaborating with other
The second issue arises from the
appointment of members of the organizations to address unmet needs.
medical staff to the board. We found
that such trustees were more likely
than most trustees to view themselves The third issue arose among against the for-profit sale option be-
(and to be viewed by other trustees) trustees at a hospital that had cause there was significant opposition
as speaking for a constituency—in weighed the merits of sale to a for- from a community group. This ex-
this case, the medical staff or the pa- profit company versus merger with a ample raises the question whether
tients. This may be appropriate, par- local not-for-profit health care sys- trustees should use their best person-
ticularly when the board has been tem. In this particular case, after al judgment in making decisions re-
composed with an eye to representing weighing the alternatives carefully, garding the institution, or make deci-
and balancing different constituen- most trustees concluded that the rela- sions that they believe will be most
cies (as is often true of system boards tive advantages of the sale were clear- acceptable in the community. The
made up of representatives from ly greater, given the purchaser’s track latter may be appropriate (assuming
component institutions). Researchers record elsewhere, its commitment to that trustees really know what the
report that inclusion of physicians on the future of the hospital, and a pur- “community” wants) if trustees are
hospital boards is increasing. Howev- chase price that would allow creation deemed to be serving in a “represen-
er, having trustees who represent con- of a local foundation. They feared tative” capacity. But is that how they
stituencies raises a fundamental ques- that the local system into which their should be viewed?
tion about whether their first loyalty assets would be merged in a non-cash The board’s value-mediation role.
should be to their constituency or to transaction would eventually close Unlike for-profit organizations, in
the hospital and/or its mission. the hospital. Even so, they decided which the decisions of boards and

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S11
managers are legitimately evaluated ways to learn how community mem- aspects of the organization’s activities.
primarily from the perspective of en- bers define their needs. However, for Yet boards of trustees are voluntary
hancing the value of stockholders’ in- hospitals located in large urban areas bodies that meet only periodically, so
vestments, the goals of not-for-profit and nearby suburbs, the identity of there are limits to the matters in
organizations tend to be ambiguous, the community may be much less which boards can take an active role.
their stakeholders multiple, and their straightforward, and likewise the As a practical matter, boards delegate
performance seldom measured solely ways that trustees can come to under- to management and often to small
or even primarily in terms of whether stand the community’s needs.14 executive committees.
the value of the assets is increasing. The trustees we interviewed had In questioning trustees and CEOs
Not-for-profit hospital trustees must little difficulty in defining the com- about the responsibilities of trustees
not only mediate among the interests munity or the communities served by at their institution, we found that
of multiple stakeholders, but they their hospital, although trustees from that about a third of the trustees and
must do so knowing that an analysis large urban teaching hospitals some- almost all of the CEOs defined
of the economic effects of the deci- times indicated that their service area trustees’ responsibilities in terms of
sion does not necessarily provide the differed according to the type of ser- their relationship with management.
criteria by which to choose among al- vice in question. However, trustees at More respondents defined trustees’
ternative strategic decisions. The not- only a handful of institutions indicat- responsibilities by relationship to
for-profit board has the difficult task ed that issues pertaining to tax ex- management than by relationship to
of assuring that the organization’s emption had been discussed in the the community and its needs, the
policies and activities contribute to its previous year. One institution had hospital’s mission, or patients. Such
mission, and of finding the necessary defined community benefit goals in CEOs and trustees almost always
resources with which to pursue that terms of the estimated value of its tax talked about the division of labor be-
mission—including aspects of mis- exemption and had prepared a report tween board and management—with
sion that cannot be rendered prof- to the community on its performance the board depicted as providing over-
itably. Moreover, the stakeholders in achieving that goal. sight of management, setting out
whose interests the hospital board A practical complication regarding policies that management carries out,
may consider, and who may not be the board’s role in assuring that their hiring and firing management, or
present when decisions are made, hospital meets community needs is supporting or providing a “sounding
comprise a lengthy list—patients, that boards often contain members board” for management.
physicians, employees, benefactors, who do not live in the community. However, most respondents indi-
purchasers of service, regulators, and They may work but not live nearby, cated that important initiatives at
policymakers. Teaching hospitals or, in a city like New York, they may their institution were either devel-
have additional stakeholders and face have been selected because of their oped jointly by management and the
commensurately increased complexi- national prominence, even though board (or board leadership) or by
ty. The board may also consider the they have little geographic connec- management itself. As trustees char-
needs and interests of the communi- tion to the hospital. In addition, ever acterized their responsibilities, they
ty, which (unlike other stakeholders) more hospitals are governed by health appear to be more reactive than
might have no voice except through care systems that have hospitals in proactive (though we did not use
the trustees. multiple communities. The boards of those terms): trustees are much more
Community benefit. Closely re- these systems may include few or no likely to describe their job as over-
lated to these first two topics is the members from some communities. sight rather than as policymaking.
expectation, established by tradition Reconciling a hospital’s community Many boards also delegate sub-
and as a condition of federal tax ex- service obligations with governance stantial authority to subcommittees.
empt status, that not-for-profit hos- by “outsiders” is a challenge that is Depending on the board’s traditions
pitals engage in “community benefit” becoming commonplace as hospitals and bylaws, subcommittees—includ-
activities. As analyzed by scholars and consolidate into systems. If place of ing executive committees—effective-
policymakers, community benefit residence or everyday ties no longer ly become the decisionmaking bodies
can take many forms—care for the suffice, then the value of local com- either in specialized areas or, in some
uninsured, involvement in educa- munity benefit activities must be cases, for the entire institution.
tional and research activities, assess- made an explicit part of board delib- The common practice of delegat-
ment of community needs, and col- erations. ing authority reaches ethical limits
laborating with other organizations Delegation of responsibility. The when it no longer serves to reinforce
to address unmet needs. For hospitals board of trustees is the highest au- responsible and competent gover-
located in small towns, the meaning thority in a not-for-profit organiza- nance. At its extreme, the practice
of “community” is relatively clear, tion, with power to hire and fire the can come to exclude some board
and trustees have various informal CEO and legal responsibility for all members, to the point where they are

S12 July-August 2002/HASTINGS CENTER REPORT


unable to discharge their duties and The economic decline of a hospi- some respondents seemed to think
become mere token trustees. tal raises another conflict regarding that an affirmative answer was cor-
Conflicting responsibilities. trustee responsibilities. If a board be- rect.
Trustees commonly frame their re- lieves that it will be unable to assure In most institutions, some respon-
sponsibility as making sure that the the future viability of its hospital, dents indicated that their board had
hospital meets the needs of the com- when should it shift its attention not made any decisions in the previ-
munity it serves. Phrased this way, from overseeing the hospital to pro- ous year that could not be justified in
there appears to be no tension be- tecting the value of its assets? Trustees terms of the institution’s economic
tween the trustee’s responsibilities to who had considered the sale of their interests, but other trustees from the
the institution (or its mission) and institutions told us that they had same institutions gave us examples of
the community. Frequently, however, come to believe that their institution just such decisions. Most examples
circumstances arise in which this was on a path toward economic ruin pertained to decisions to maintain the
comfortable formulation of responsi- because of debt, capital needs, and hospital’s commitment to providing
bilities does not work. For example, occupancy problems, and that it uncompensated care to the unin-
many decisions that may be good for would be worth progressively less sured, decisions to establish or main-
the community (or segments thereof) each year. Trustees who define their tain money-losing services that were
may be costly to the institution. responsibility as preserving their insti- either used by low-income popula-
In our survey, some trustees de- tution may be less likely to act on tions or were necessary (though un-
fined their responsibilities in terms of such a belief—or even to accept that profitable) to maintain the hospital’s
assuring the well-being of the institu- their hospital is in such a crisis—than excellence, or decisions to maintain
tion, while others focused more on are trustees who view themselves as the commitment to research and
furthering the institution’s purpose, responsible for maintaining or in- training.
which was usually defined in terms of creasing the value of the assets with Finally, several respondents were
meeting patients’ or the community’s which they have been entrusted. ambiguous. They indicated that their
needs. Tensions between these per- Social versus economic values. board had made a decision that could
spectives can arise in ordinary budget Many trustees we interviewed experi- not be justified in economic terms,
situations—such as deciding whether enced a tension between social and but when asked for an example, they
to close the money-losing clinic that economic values in decisions regard- either could not think of any or they
serves a low-income population. Situ- ing the hospital. This tension was described a decision that they then
ations in which the institution’s con- highlighted in their responses to our justified in business terms. For exam-
tinued economic viability comes into question whether their board had ple, one trustee cited the decision to
question can throw the tensions be- made any decisions in the past year merge with a money-losing hospital,
tween perspectives into particularly “that could not be justified in terms but then said that while it might ap-
high relief. In those cases, institution- of the economic interests of their hos- pear that this merger was against the
al preservation may have to be pital.” hospital’s economic interest, the real
weighed against the continued avail- Some trustees seemed to feel that purpose was to strengthen the hospi-
ability of services in the community, they would be confessing to irrespon- tal’s economic position in the long
as when a merger may preserve ser- sibility if they answered affirmatively. term.
vices at the cost of institutional iden- As one trustee said, “We try not to,
tity. but it happens.” On the other hand,

THE ETHICS OF HOSPITAL TRUSTEESHIP

S ome insight into the nature of a


trustee’s ethical responsibilities
comes directly from the preceding
term “ethics” itself is not generally
used as a label to describe what the
trustees are experiencing.
that affect the lives and well-being of
a large number of people who are rel-
atively powerless, relatively vulnera-
discussion of the kinds of pressures It is also possible to think about ble, and in need of services or assis-
trustees are under and the kinds of the ethical responsibilities of hospital tance. Such people have a stake in
decisions they have to make. Our in- trustees by inference from the ethical hospital governance, but no voice in
terviews with trustees, CEOs, and responsibilities of the trustee role in it. They have a stake not only because
other senior managers also indicate any not-for-profit setting. It is impor- the hospital care is a vital community
that, in effect, ethical duties often tant not to lose sight of the fact that service, but also because the hospital
weigh significantly in their everyday trustees both inside and outside received civic support in the form of
thinking and action, even though the health care regularly make decisions its tax exemption.

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S13
Moreover, a sense of the ethical herent and systematic framework. We tution is rooted in the past and in the
importance of trusteeship is suggest- offer below one such framework, or- tradition of the institution, but it also
ed by the word “trust” itself. Trustees ganized around four general princi- points toward the future. A mission is
have been entrusted with responsibil- ples. The first of these is called “pri- a dynamic thing, an overriding pur-
ity for a set of assets and a mission. mary” because it lays the foundation pose that changes with changing en-
Those assets have been created by pri- for the other principles, but all four vironment and circumstances, and
vate donation and public action, and principles are essential in giving trustees are faithful to it when they
trustees are responsible for seeing that trustees the proper ethical orientation adopt an open-minded orientation. A
those assets are used to serve the pub- and in doing justice to the ethical sig- mission does not interpret itself any
lic interest in accord with the organi- nificance of the trustee’s role. more than it implements itself. It is in
zation’s mission. Furthermore, need of ongoing interpretation and
trusteeship is specific: it is always at- Principles of Ethical reflection, much as is the Declaration
tached to a mission and an institution Trusteeship of Independence in American politi-
that has a history, a moral identity, cal theory or the Constitution in
and a community presence. These el- Fidelity to mission. The primary American law.
ements should be respected and fac- principle of the ethics of trusteeship Fidelity to mission must also be
tored into any ethically responsible can be stated as follows: Trustees understood so that it is compatible
decisions by trustees.15 should use their authority and best ef- with the demands of ordinary moral-
forts justly to promote the mission of the ity. Even a narrow mission would not
give a trustee carte blanche to ignore
either the law or the requirements of
The generic mission of the not-for-profit hospital is general morality. If one were a trustee
of an organization whose traditional
comprised of three objectives: to promote the health and mission was written in terms that
once implied racial or religious dis-
well-being of patients, to be a civic and health resource for crimination, then in light of today’s
moral norms and laws, the mission
the community, and to be a place of respectful, should be reinterpreted in such a way
that such discrimination was neither
well-managed, and competent health care provision. implied nor tolerated. Hospitals, like
virtually all other institutions, used to
be racially segregated in America;
Each of the roles and occupations not-for-profit organization, and to keep trustees apparently once thought that
that exist in a society can be looked at that mission alive by interpreting its their duty to the hospital’s patients
from two complementary points of meaning over time in light of changing (at least its white patients) required
view. They can be considered both in circumstances. segregated wards. But today, fidelity
terms of the social functions they per- The mission of the organization to mission is perfectly compatible
form and in terms of the ethical or governed by trustees is central to the with—indeed would be seen as re-
cultural norms and values they em- ethics of the trustee role because it is quiring—racially integrated patient
body. The ethics of trusteeship is a the cornerstone of all of the trustee’s care settings.
framework of normative expectations other responsibilities. The board ex- When we apply this primary prin-
that constitute the role of trustee, ists to direct the organization, but the ciple to the setting of the not-for-
much as physician ethics sets forth in organization exists to pursue and ful- profit hospital, three aspects of mis-
a systematic way the normative ex- fill a mission, a moral and social ob- sion come to the fore and suggest
pectations that society invests in its jective. Without the mission, there more specific principles of trustee
doctors, or as professional legal ethics would be no trustee role in the first ethics. The generic mission of the
contains the norms that society holds place. not-for-profit hospital is comprised
for its lawyers. It is important to interpret this of three objectives: to promote the
Like the professions, trustees are principle broadly. Fidelity to mission health and well-being of patients, to
expected to adhere to ethical stan- should not be interpreted to mean be a civic and health resource for the
dards over and above what is called that the exclusive role of the trustee is community, and to be a place of re-
for by ordinary morality, and in re- to perpetuate the past or to resist spectful, well-managed, and compe-
turn granted significant power and change. The “mission” is not neces- tent health care provision. Thus in
prerogatives. The problem is to orga- sarily the document that the organi- addition to the principle of fidelity to
nize the normative expectations and zation refers to as its “mission state- mission, trustee ethics in the hospital
demands placed on trustees into a co- ment.” The true mission of an insti- includes three principles of service:

S14 July-August 2002/HASTINGS CENTER REPORT


service to patients by providing med- where individuals receive care or problems that are at root civic and
ical, nursing, and allied health care; high-quality professional medicine is systemic in nature.
service to community by, among practiced; they are also resources ded- Hospitals alone cannot cure civic
other things, promoting health; and icated to improving the public health or community problems, and in
service to the hospital through stew- and quality of civic life of the com- today’s health economy they are
ardship on behalf of that uniquely munity as a whole. The health ser- sometimes hard pressed to attend
valuable social institution. vices hospitals provide are integral even to the acute and emergency care
Service to patients. Fidelity to the components of a community’s identi- responsibilities. But ethically respon-
hospital mission calls for trustees to ty and traditions. Trustees do well sible trusteeship requires a willingness
adhere to a principle of service to pa- when they bear that in mind and un- to participate with other civic leaders
tients and to their health needs: derstand the interconnection between in the search for broader community
Trustees should ensure that high quality what goes on inside the hospital and enhancement and civic renewal ef-
health care is provided to patients in an what occurs in the community out- forts.
effective and ethically appropriate man- side. A hospital, least of all a not-for-
ner. The principle of service to the profit hospital, is not simply a busi-
This principle is a requirement of community recognizes this dimen- ness that sells something to the com-
diligent oversight of management sion of the trustee’s role and the hos- munity out of self-interest. Neither is
and of the hospital’s performance. It
also calls upon trustees to support the A hospital may sometimes function like a business, and
promotion of health in manifold
ways, including by mobilizing re- sometimes it will be called upon to be a charity, but above
sources for professional medical,
nursing, and allied health services, by all it is a civic institution. It takes cognizance of the quality
participating in professional educa-
tion and biomedical research, by pro- of civic life in the broader community.
viding chronic and palliative care,
and by sustaining a meaningful and
dignified quality of life for patients. pital’s mission: Trustees should govern a hospital designed to give something
It requires that trustees protect hospital policy and deploy hospital re- to the community out of voluntary
and promote the rights and interests sources in ways that enhance the health charity—even if it is a not-for-profit
of patients by maintaining hospital and quality of life in the broader com- hospital. A hospital may indeed
policies and procedures in support of munity that the hospital serves. sometimes function like a business,
patient autonomy, informed consent, The mission of the hospital can- and sometimes it will be called upon
respect for privacy and confidentiali- not be successfully pursued in isola- to be a charity, but above all it is a
ty, and the like. Trustees should en- tion from the nature and quality of civic institution.17 It takes cognizance
sure that hospital practice includes the surrounding community. Service of the quality of civic life in the
the patient, and when appropriate the to patients and families neither begins broader community because its very
family, as a partner in decisionmaking when the patient enters the hospital essence as an institution is at stake in
about health care and medical treat- nor ends when she is discharged.16 efforts to promote public health and
ment. This is one area where the scope of its participation with other commu-
This principle enjoins trustees to ethical responsibility is considerably nity institutions in the ongoing task
take steps to ensure that limited hos- broader than that of legal responsibil- of civic preservation and renewal.
pital resources and services are uti- ity or liability. Institutional stewardship. Judging
lized efficiently and effectively. When Emergency rescue and acute stabi- by the interviews we conducted with
difficult distributive decisions must lization are only the tips of the ice- trustees and CEOs, nearly all trustees
be made, they should be handled in a berg of health care needs in today’s would agree with the emphasis we
just and equitable fashion so that society. Chronic illness and disability, have placed on patient service and
quality of care is not substantially behaviorally related health risks, com- service to the broader community.
compromised and so that the effects munity mental health services, and They might not call these issues mat-
of such decisions do not fall unfairly the provision of adequate housing, ters of “ethics,” but they do acknowl-
or disproportionately on the most nutrition, and support systems, both edge the norm and the sense of re-
vulnerable or the poorest patients. familial and professional, are the keys sponsibility nonetheless. They recog-
Service to the community. to serving the needs and rights of pa- nize even more readily, however, their
Throughout American history, hospi- tients in the broader context of their role in hospital governance and insti-
tals have been understood as civic in- lives. It makes little sense to repeated- tutional stewardship, responsibility
stitutions. They are not only places ly treat the individual symptoms of and leadership.

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S15
Hence the principle of institution- ethical integrity as an institution. Fulfilling the duties of this princi-
al stewardship: Trustees should sustain Trustees are not entrusted simply ple requires certain kinds of conduct
and enhance the integrity of the hospital with the governance of the hospital as by individual trustees, certain kinds
as an institution, as an effective organi- an “asset,” as a property with a certain of conduct by the board of trustees
zation for the delivery of high quality market value. They are also—and no collectively, and support for certain
health care services, and as a moral less significantly—entrusted with the kinds of governance, administrative,
community of caregiving. care of the hospital as a vibrant and and clinical policies and practices
Trustees are entrusted with the viable social and cultural system, a throughout the hospital. Here the
hospital’s mission, but in practical moral community comprised of general orientation offered by princi-
terms that translates into working many individuals from varied back- ples meets the more specific duties
with the executive management of grounds with diverse needs, skills, that trustees should fulfill when mak-
the facility to ensure that it is well and contributions to make to the ing particular decisions and taking ac-
run, fiscally sound, and professionally whole.18 tion. And the duties of trustees as in-
competent. In short, trustees must Of course, this does not mean that dividuals meet the issue of the proper
protect the interests of all parties who a hospital should never be closed and organization and functioning of the
rely on the hospital or are significant- its monetary value liquidated or con- board as a collective decisionmaking
ly affected by its activities, in addition verted to another socially beneficial system through which individual
to protecting the hospital’s financial use. Some hospitals have outlived trustees exercise their own ethical re-
assets and its license and accredita- their mission and their usefulness in a sponsibilities. The principle of insti-
tion. particular community; others, tutional stewardship closes the circle
Each of these duties is vital and through mismanagement, the depar- on this relationship, so to speak. It re-
ethically significant, and they form a ture of key personnel, or lack of re- minds trustees that, even as the prop-
part of what is meant by institutional sources have lost the ability to provide er functioning of the board (and of
stewardship. But the principle we for- an adequate and competent level of the hospital as a whole) enables them
mulate here is intended to go beyond service to their patients and the com- to fulfill their duties, so too each indi-
these standard and well-recognized munity. The responsibility of trustees vidual trustee has a duty to help cre-
fiduciary obligations and to encom- to perceive when a hospital is no ate and sustain a well-functioning
pass the notion that ethical trustee- longer viable is as important as the re- board.
ship is responsible for the mainte- sponsibility to fight to ensure the hos-
nance and flourishing of the hospital’s pital’s viability and survival.

TRUSTEE ETHICS IN PRACTICE


Conflict of Interest
T he principles of fidelity to mis-
sion, service to patients, service
judgments, come to conclusions, and
make decisions. The system can be as
to community, and institutional
stewardship provide only the proper
grounding and orientation for indi-
large as the hospital, even the com-
munity as a whole. But the most im-
mediate and important system that
T he phrase “ethical issues in hos-
pital trusteeship” often calls to
mind problems related to conflicts of
vidual trustees and for boards; they affects ethics in the practice of interest. A conflict of interest can
represent the first, not the last, step in trusteeship is the functional organiza- produce a violation of any or all of
assessing the ethical quality of specif- tion of the board itself.19 By this we the ethical principles we have de-
ic policies or decisions, by individual mean the relationships among the scribed.
trustees and boards, in particular hos- trustees and with the chair. It also in- A conflict of interest arises when a
pitals. cludes the nature of the relationship trustee might personally benefit from
The next step, which leads into between the board (and especially the his or her official actions or influence
the domain of ethical decisionmaking chair) and the CEO, senior hospital and when the expectation or pursuit
in practice, requires attention to two administration, hospital medical of personal interest can bias decisions
broad topics. The first is the conduct, staff, nursing staff, and other con- that are made by the trustee in his or
reasoning, judgment, and motivation stituencies in the hospital.20 Finally, her official capacity. The potential for
of trustees as individuals. The second beyond the boardroom, one must personal gain may influence decision-
is the condition of the “system” or en- consider the relationships between making indirectly (the trustee may
vironment within which individual the trustees and important stakehold- vote a certain way to win favor with a
trustees receive information, make ers outside the hospital. potential colleague) or the influence

S16 July-August 2002/HASTINGS CENTER REPORT


may be direct and overt (the trustee trusts during their period of service. Several components of board or-
may vote for a particular construc- As members of small communities, ganization and functioning play a
tion project with the guarantee that trustees will routinely have business key role in contributing to effective,
the bid will go to his construction interests that intertwine with hospital ethically responsible decisionmaking
company). business and could set up at least the by trustees. These include a clear un-
Conflicts of interests can be han- appearance of a conflict of interest. derstanding of the institution’s mis-
dled by such means as financial di- Perhaps even public disclosure re- sion and functioning, timely and ac-
vestment, open competitive bidding quirements would be a significant de- curate information, a process for
requirements, recusal from involve- terrent to volunteer board service. thorough deliberation and consen-
ment in certain board activities or de- This is even more complex in today’s sus-building, and mechanisms for pe-
cisions, and by public disclosure of climate, which has prompted a num- riodic review of CEO performance
assets and interests so that others can ber of boards to open their member- and board performance. This is not
be alerted to a potential conflict in ship to practicing physicians, despite the place to discuss these compo-
the trustee’s situation. Not all of these the inherent conflict of interest such nents in detail.21 Here we offer only a
steps are equally necessary or feasible trustees have. Yet even as these ques- brief overview, highlighting points
in every situation. Boards should tions become more complex and nu- that are particularly salient to
have general policies for disclosure, anced, they also become more ur- trustees’ ethical decisionmaking and
recusal, and prohibited activities. gent. Public suspicion of the motiva- to fulfilling the ethical principles of
When special circumstances arise, tions of health care institutions and trustee service.
trustees will have to decide on the
right course of action for themselves
on a case-by-case basis. Individual When fundamental values and principles come into
members ought not be the sole ar-
biter of whether there are, or appear conflict, how the board decides can be as important as
to be, conflicts of interest for them-
selves. From an ethical point of view, what the board decides. When questions of mission,
the most important rule is that, how-
ever it is to be accomplished, trustees service, quality, or justice are at stake, boards should
must be free from improper influ-
ences that might skew or taint their ensure that all points of view are heard and taken
independent judgment. Trustees
should never use their position with seriously, that reasonable compromise is explored, and
the hospital primarily for the purpos-
es of personal or familial financial that consensus has time to form.
gain. To sustain the trust that the
broader community has in the hospi-
tal, trustees should also avoid the ap- practitioners is on the rise, and hospi- Information. The information
pearance of a conflict of interest, and tals risk losing one of the most valu- needed for good board deliberation
when such an appearance exists, able of their assets, if not the most comes from both inside and outside
should act cautiously so as to mini- valuable—the trust of their patients the institution.22 The board should
mize it. and of the public at large. ask: What information do we need to
These questions become more dif- make our decisions? What are and
ficult in a health care economy that is Board Structure and Functions what should be the sources of our in-
producing many unprecedented and formation? Is the information that
complex financial and business deal-
ings for hospitals and physicians. In
fact, conflict of interest is a very sub-
T rustees have a responsibility to
assure the soundness of the
board’s structure and functioning, al-
we have sufficient? Is there a need for
special methods or formats the board
should use to review complex infor-
tle and difficult question in health though many of the operational du- mation? Do we need to obtain infor-
care, and it is not always obvious ties will fall to management. Periodi- mation from outside the institution
what the evil is to be avoided or that cally, boards should review the hospi- by means of a survey or some other
the remedies are not worse than the tal’s mission (perhaps also the official mechanism? As individuals, trustees
disease. mission statement), the composition can exercise responsible institutional
It seems draconian to require vol- of the board, and its operating proce- stewardship only if they have a basis
unteer trustees to divest themselves of dures, committee structure, and the for independent decisionmaking and
all holdings that might be affected by like. judgment. They must insist that
the hospital or even to set up blind management provide them with

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S17
whatever information is necessary to At best, the board should be able to home disappointed to return another
make decisions wisely, prudently, and offer a clear justification and ratio- day.
in the best interest of the hospital’s nale for giving greater weight to one An ordinary part of the responsi-
integrity. It is essential for trustees to value than another—for valuing in- bilities of most boards, in collabora-
do their homework and to keep digent care more than profitability, tion with the hospital administra-
themselves well informed about the for example. tion, is not only setting or approving
hospital’s various activities and ser- Regarding the process of decision- new policy, but also periodically re-
vices. To make this goal manageable, making, the board must operate on viewing previous policies. Here too,
trustees and CEOs should work to- the basis of fair and democratic rules, mechanisms of evaluation and delib-
gether to support various mecha- although the board chair and com- eration are important. Trustees
nisms for reporting and cooperating mittee chairs obviously will wield should make sure that those mecha-
with hospital management and vari- considerable influence. Volunteer nisms provide the timely and accu-
ous approaches to board organiza- trustees with limited time to devote rate information necessary for re-
tion, such as specialized committees to their board work will rightly defer sponsible decisionmaking at the
responsible for different areas. to those who have studied an issue board level. One particularly impor-
Board composition and delibera- longer or bring greater experience or tant aspect of this is to ask whether
tion. Trustees should ask: Is the com- expertise to it. Nonetheless, each feedback loops are in place to inform
position of the board appropriate? trustee should have an opportunity the board about how policies are af-
Do we have appropriate term limits to participate fully in board delibera- fecting patients, families, and staff,
for trustees? Do we have a procedure tions. Sometimes, too, it is necessary the community, and other stakehold-
for assessing the disclosure state- and appropriate for individual ers of the hospital.
ments of trustees? Is the role of trustees to openly state their disagree- Engaging in constructive self-as-
trustees to represent or advocate for ments and voice alternative points of sessment about board functioning
particular constituencies? view. A strong and effective chair will and other institutional processes can
Regarding the quality of the not stifle debate or force agreement, lay the groundwork for good ethical
board’s deliberations, trustees should but will utilize the trustees’ diverse decisionmaking. In addition, such a
ask: Do we have an open deliberative talents and opinions to further the reflective process can contribute to
process? Do we allow all voices to be goals of wise counsel and good deci- an institution’s organizational ethics
heard? Have we deliberated on the sionmaking. by explicitly addressing institutional
basis of a clear understanding of our When fundamental values and obligations at the highest level of the
mission? Have we made explicit the principles come into conflict, how organization.
principles on which our deliberations the board decides can be as impor-
are based? When principles come tant as what the board decides. In Shared or Federated
into tension or conflict, have we routine day-to-day decisionmaking, Governance
weighed the merits of each? Do we boards operate well by following ma-
have a clear justification for balanc-
ing them in a particular way? Do we
have an appropriate procedure for
jority rule, sometimes even by defer-
ring to individual trustees who have
special expertise or particularly in-
T oday, many hospitals are part of
larger systems or networks and
hospital boards may be subsidiary to
determining the consensus? tense interest in the issue. But when the decisional board of the parent
In engaging complex questions, fundamental questions of mission, system. This trend raises two unique
the board should have an open delib- service, quality, or justice are at stake, ethical issues.
erative process, one based on all per- boards should take extra time to Allocation decisions by the par-
tinent information and all pertinent make certain that each trustee under- ent board. The board of an individ-
values relevant to the hospital’s mis- stands the issue and the alternatives. ual hospital must make allocation de-
sion. No trustee should dominate the It should ensure that all points of cisions between services. Likewise,
discussion or suppress discussion of view are heard and taken seriously, the board of a hospital system—the
pertinent values. At times it will be that reasonable compromise is ex- decisional board—must make alloca-
necessary for trustees to explicitly jus- plored, and that consensus has time tion decisions regarding its subsidiary
tify their positions on the basis of to form. The rule of unanimity is hospitals. In both cases, values such
ethical values, and the discussion usually impractical, but the spirit of as justice, equity, efficiency, and com-
should allow for the identification of compromise, mutual respect, and munity well-being should guide deci-
tensions or conflicts between values consensus is the best soil from which sionmaking. It is not enough, for ex-
and other objectives or interests. Al- sound ethical decisions spring. It is ample, to decide that a subsidiary
though it will often be necessary to also the spirit that keeps boards oper- hospital will be closed or experience
weigh competing values, there is no ating after the tough decisions have cut-backs because it is inefficient.
mathematical formula for doing so. been made and the losers must go The inefficiency must be explained.

S18 July-August 2002/HASTINGS CENTER REPORT


Is the hospital inefficient because should in most cases allow two Relations between Trustees
and Hospital Staff
community demand has declined? boards to come to agreement.
Because it serves a sicker population
than other network hospitals? These
considerations are central to the ser-
vice mission of the hospital system
Relations between Trustees
and the Hospital
Administration
T rustees, individually but especial-
ly collectively, should safeguard
internal policies and practices that are
and to the demands of ethical delib- vital to the institutional integrity of
eration. Decisions that are made sole-
ly on the basis of short-term return
on investment do not sufficiently en-
W hen discussing the institution-
al system or environment
within which trustees work, it is ap-
the hospital as a place of competence
and efficiency and as a place of moral
community, mutual respect, and hu-
gage the important noneconomic val- propriate to give special attention to mane care. Three types of policies
ues at stake in these decisions. the relationship between trustees and and procedures are noteworthy here,
Trusteeship on subsidiary boards. the hospital administration, particu- although many more could be added.
The relationship between a decisional larly the hospital CEO. The principal One pertains to quality of care.
and subsidiary board may take a vari- responsibility of all trustees is to se- This includes the mechanisms of
ety of forms, each reflecting the de- lect, support, and monitor the perfor- continuous quality improvement,
gree of discretion granted to the sub- mance of the hospital’s CEO. And it quality assurance, the reduction of
sidiary. In the worst case, the sub- is through the medium of providing medical mishaps and mistakes, the
sidiary board could find that acting the hospital with a qualified and ef- prevention and control of nosocomi-
morally is impossible because the fective managerial leader that trustees al infection, and the mechanisms of
board has no power or discretion. indirectly act in service of the princi- hiring staff and granting practice
When a subsidiary board is forced ples of fidelity to mission, and service privileges to physicians.23
to comply with a directive with to patients, community, and institu- Another area involves clinical de-
which it strongly disagrees, the sub- tion. Without the foundation of a cisionmaking and patient care, in-
sidiary is faced with the classic prob- good CEO and a good relationship cluding the functions of hospital
lem of complicity. Should the board between the CEO and the board, it ethics committees, policies regarding
“go along to get along,” resign, or becomes much more difficult for in- life-sustaining treatment such as arti-
continue, attempting to mitigate dividual trustees to perform their du- ficial nutrition and hydration, ad-
harms that it believes will follow from ties well. vance directives, family or surrogate
the directive? In the face of moral ob- Diligence in the selection and pe- decisionmaking when patients lack
jection, “going along to get along” is riodic evaluation of the CEO is a decisionmaking capacity, and proto-
unacceptable. It degrades the board’s paramount responsibility. Ongoing cols for palliative care.24
moral integrity. A sitting board still working relations and regular, timely A third area that is key to institu-
has an obligation to serve the mission communication are no less impor- tional integrity and should be moni-
of the hospital. Resigning would de tant. Trustees must often rely on the tored by attentive trustees involves
facto remove that obligation, but it hospital administration for the infor- nondiscrimination and civil rights
would also remove the board’s moral mation upon which they base board policies governing employee relations
authority, which in situations such as decisions, and therefore a climate of and benefits, and the interaction
these may be the board’s only author- trust and mutual respect is essential among hospital staff and between
ity. Remaining as a sitting board and to effective board functioning and staff and patients.
attempting to influence policy in the trustee performance. Mutual respect We mention these matters of in-
interests of the institution is the most is the key. Trustees should not be ternal policy and practice not to rec-
difficult choice, but it is likely to be overly intrusive in their governance; ommend that trustees become micro-
one that best conforms to the board’s they should allow their CEO to lead managers. But far short of micro-
ethical obligations. The answer to and to manage, and should not un- managing, trustees do have an obliga-
this question will depend on the co- dermine his or her authority or en- tion to maintain the accountability of
hesiveness of the subsidiary board as croach on expertise. At the same management and to keep themselves
well as the prospect of success. time, CEOs should respect their informed about the patterns of inter-
This is admittedly a worst-case trustees and the legitimate, indepen- nal hospital life. These are not areas
scenario. Ideally, the relationship be- dent role they play in the governance where trustees and CEOs ought to be
tween the decisional board and the and oversight of the institution. at odds; on the contrary, their roles
subsidiary board would be respectful Trustees and CEOs are most effective should be complementary and sym-
and mutually supporting. Open de- when they assist each other. biotic. Trustees can and should main-
liberation using ethical principles and tain a breadth of vision about the na-
commitment to mission as guides ture of the hospital as an institution
and its moral integrity. Trustees are in

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S19
a favorable position to do this precise- patient service calls trustees into that The issue of control and decisional
ly because they are neither managers vital duty as well. Ideally, therefore, autonomy is ever present in the orga-
nor health care professionals. Their the common goal of providing high- nizational life of the hospital. Person-
distance from the day-to-day prob- quality care to patients will provide ality and openness to dialogue are
lems of hospital management and common ground for clinical staff and often key aspects of working relation-
from the exigencies of clinical medical trustees. This ideal is not translated ships and the basis on which they
or nursing practice can work to their into practice at many hospitals. Yet may succeed or fail. Thus trustees
advantage in fulfilling the principle of the history of the relationship be- should take steps to ensure that lines
institutional stewardship. tween trustees and medical staff, as of communication are kept open be-
Benefiting patients is a defining well as that between the trustees and tween the board, the administration,
obligation of the health professions. the hospital administration, is rife and the medical staff.
What we have called the principle of with shifts in power and authority.

HARD CHOICES

I n order to illustrate how the ethical


perspective offered in this paper
can illuminate the dilemmas and
tions on economic restructuring may
involve eliminating a hospital service
such as pediatrics or the emergency
stewardship enjoins the duplication
of resources and services that may
characterize a competitive health care
hard choices hospital trustees face, we department because it is no longer a market where hospitals are vying for
patients. Under some circumstances,
therefore, the principle of steward-
The ethical limit on the board’s responsibility to ship may justify a decision to close a
service, even the hospital itself, if
constituencies and overseeing bodies is its doing so serves the broader mission
of more efficient and accessible care.
responsibility for the goods articulated in the mission. In secular hospitals, the principle
of stewardship is also tied to institu-
To the extent that the interests of oversight bodies or tional mission. Deliberating about
the most cost-effective way to ad-
constituencies are at odds with the mission, the board vance the mission will again depend
on the demands of the mission and
has a responsibility to decide on the basis the community impact. If a board
decides that stewardship requires cut-
of its obligation to the mission. ting back on service, responsibility to
the community entails informing the
community and assisting in the de-
close by considering three difficult “revenue stream.” A board’s decision velopment of a plan to accommodate
kinds of problems confronting not- regarding the possible closure of a the community services lost in the
for-profit hospitals and boards of clinic should focus not only on the fi- closure.
trustees. nancial considerations but also on The issue of clinic or hospital clo-
Decisions to close a hospital or the impact that such a decision will sure points to two important board
clinic. The decision to close a hospi- have on the community and its access responsibilities. The first is that the
tal or a clinic or department is one of to services. Likewise, trustees should board be proactive in monitoring the
the most difficult a board addresses, explicitly discuss whether the deci- institution for signs of financial dis-
but it is also one that can be effec- sion is compatible with the hospital’s tress and respond to these signs be-
tively guided by the principles of fi- stated mission. fore the closure decision is imminent.
delity to mission, service to patients The principle of stewardship re- The second is that the board look for
and the community, and stewardship quires that the resources governed by alternative scenarios to closure. Ex-
of the institution. a board be used wisely. “Wisely” ploring alternatives is a requirement
In this era of cost containment means in a manner consistent with of stewardship and a necessary com-
and consolidation in health care, the moral aims of the institution. In ponent of board deliberation. Our re-
small hospitals often find that they the case of faith-based health care in- search suggests that conflicts of inter-
must affiliate with former competi- stitutions that have a broad mission est on the board are likely to adverse-
tors in order to survive. The negotia- of service to the poor, the principle of ly affect decisions regarding the fate

S20 July-August 2002/HASTINGS CENTER REPORT


Emergency Pediatric
Waiting Room
by May H. Lesser, ©1989 Tulane
University Medical Center

of an institution and undercut the le- stakeholder interests that trustees Not only the principle of fidelity but
gitimacy of whatever decisions are should serve. also that of service to the community
made. Thus boards should be espe- Deliberation about these matters (civic responsibility) supports this
cially alert to the ways in which vest- requires explicit consideration of two view. The existence of not-for-profit
ed interests may hamper efforts to additional ethical questions. First, hospitals depends on significant tax-
remedy financial distress or to limit whether and how should the board advantages, patient stream, and com-
alternative scenarios. solicit community values to inform munity support. Reciprocity thus re-
Affiliations and conversions. its decision? The board has an obliga- quires the hospital to serve the com-
Among the trustees we interviewed, tion to listen to community view- munity in a way that is responsive to
the question of affiliation (through points and to share its reasoning with its particular needs.
merger, partnership, or conversion, the community. Second, if the hospi- The second question, regarding
for example) was identified as the tal in question is part of a larger sys- consideration of the interests of the
most important issue that had occu- tem, how should the boards both of community, the particular hospital,
pied boards at the end of the 1990s. the hospital and of the system weigh and the hospital system of which it
Affiliation raises a number of ethical the interests of the system, the hospi- may be a part, raises the important
considerations that boards should ex- tal itself, and the community of issue of negotiating responsibility. On
plicitly address. These include the which it is a part? the one hand is the board’s account-
trustee’s obligation to preserve the The first of these questions touch- ability—that is, its “responsibility to”
hospital mission and the obligation to es on a feature of all trustee-governed its constituencies and overseeing bod-
prudently manage the hospital as an activities, namely the problem of pa- ies. On the other hand, the board also
“asset.” Ordinarily, a high burden of ternalism. There are good reasons bears a “responsibility for”: it is re-
evidence should be required before why a board should not presume to sponsible for preserving and effectu-
trustees decide to abandon the histor- know the best interests of the com- ating the stated mission of the institu-
ical mission of a charitable institu- munity it serves. Above all, the board tion. The notions of independent
tion. It is never a decision to be taken may simply be wrong. It may be too judgment and accountability require
lightly. In some cases these two oblig- parochial, for example. The hospital’s that board decisions be sensitive to—
ations will be compatible, even mutu- mission, therefore, and fidelity to that but not determined by—these perti-
ally supporting. In other cases they mission is authenticated by the com- nent interests. Thus the ethical limit
may conflict, and the board will need munity, through needs assessments, on the board’s responsibility to con-
to weigh and balance conflicting ob- surveys, public hearings, and commu- stituencies and overseeing bodies is its
jectives in light of the values and nity representation on boards or re- responsibility for the goods articulat-
porting committees of the hospital. ed in the mission. To the extent that

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S21
the interests of oversight bodies or sions of such a shift but also the inter- vices, and uncompensated care in
constituencies are at odds with the ests of the community and the pa- particular. The values conflict at issue
mission, the board has a responsibili- tients and the ethos of the institution. here is often colloquially referred to as
ty to decide on the basis of its obliga- The decision to convert from not- “margin versus mission.”
tion to the mission. for-profit to for-profit status, once The starting point for approaching
At times, however, the mission it- made, is the last opportunity the sit- this conflict is recognition that the in-
self will be ambiguous. Appeal to mis- ting board will have to negotiate on stitution’s not-for-profit status impos-
sion alone will not settle the the basis of the institution’s historical es certain obligations that the institu-
quandary. This as well as the potential mission. Conversion from not-for- tion will, through its mission, serve
conflicts between a board’s various profit to for-profit status shifts the stakeholders. One of these is the com-
obligations points to the some of the legal responsibility of the institution munity. Thus the not-for-profit hos-
most difficult aspects of the role of from community stakeholders to pital, as a civic institution, has an
the board as an arbiter of community shareholders. Inevitably, this shift nar- obligation to serve the sick who can-
and institutional values. rows the new institution’s perceived not pay for their care. This obligation
In deliberating about the sale, ethical obligations. As a not-for-prof- should remain in the forefront of
merger, and ultimate control of the it board considers conversion, it board fundraising efforts as well as
hospital, therefore, trustees must fol- should explore the possibilities for budgetary considerations. When the
low a decision procedure that explic- preserving features of its mission that board faces a decision about the goals
itly considers the financial value of might otherwise be lost. These possi- to set for uncompensated care, it
the hospital and the interests of stake- bilities include the provision of un- should keep in mind the community’s
holders relative to the mission itself. compensated care, the involvement of needs and the institution’s record on
Embedded in the question of affil- community members on the new charity care. The institution’s finan-
iation or merger is the issue of a board, and the provision of particular cial health is also pertinent to these
board’s deciding to give up its status services to patients and communities. deliberations, but if charity care is
as a decisional body to become a sub- If a hospital’s financial situation is continually threatened because of fis-
sidiary to a parent board. The ideal dire, it will clearly have little negotiat- cal priorities, this is an indication of
outcome in such a situation is maxi- ing power. For this reason, it is essen- financial distress in the institution
mization of the resources supporting tial for the board to actively monitor and should be considered a signal in
the institution’s mission and mini- the institution for signs of financial the board’s overall monitoring.
mization of the loss of autonomy. distress and to act before it complete- If deliberation about uncompen-
Tradeoffs between these two goals are ly collapses. sated care is prompted by the needs of
likely, however, as the institution is no Money losing services. At times, a particular patient, the board must
longer self-sovereign. In deliberating the board of a not-for-profit hospital be guided by values of equity and
about tradeoffs, the board should may need to consider the limit of its nondiscrimination in its deliberation.
consider not just the financial dimen- ability to provide money-losing ser-

CARRYING ON WITH THE CONVERSATION

W e hope to have gone some way


toward setting an agenda of
topics and ideas for an increasingly
of Not-for-profit Hospital Trustees
developed a curriculum for a model
workshop on trustee ethics designed
following recommendations to pro-
mote these goals.

energized and widespread conversa- primarily for trustees and other hos- Recommendation 1:
tion about trustee ethics, both within pital leaders and professionals. The
various hospital boards and the design of the workshop and cases pre- National, state, and local trustee orga-
trustee community across the coun- pared for use in it are printed with nizations should give higher priority to
try, and between trustees and the var- this report (pp. 522-523). trustee ethics in their educational and
ious stakeholder groups concerned If a richer discussion of trustee service programs.
with the functioning of American ethics is to develop and if trustees are One difficulty in reaching hospital
hospitals. That would be virtually all to be assisted in clarifying concepts trustees is that few activities, except
of us. and applying ethical principles in board meetings and other hospital
To further this goal, The Hastings practical decisionmaking, then the function themselves, are organized
Center and The New York Academy support and initiative of other organi- around this facet of their lives. When
of Medicine Task Force on the Ethics zations will be needed. We offer the they do come together under the aus-

S22 July-August 2002/HASTINGS CENTER REPORT


pices of their role as trustees it is often vote attention to ethical issues for their 7. F.A. Sloan, “Commercialism in Non-
in conjunction with periodic meet- trustees. profit Hospitals,” in To Profit or Not to Prof-
it: The Commercial Transformation of the
ings or conferences sponsored by hos- Probably the best way to reach Nonprofit Sector, ed. B.A. Weisbrod (Cam-
pital or trustee associations. That is trustees is through the hospitals they bridge: Cambridge University Press, 1998),
when presentations, panels, or work- serve. Various programs to assist and 151-68.
shops relating to trustee ethics would inform board members already exist 8. Stevens, In Sickness and in Wealth; D.
have the greatest chance of making and provide an infrastructure for pay- Rosner, A Once Charitable Enterprise: Hospi-
and impact. tals and Health Care in Brooklyn and New
ing more explicit attention to ethics. York, 1885-1915, (New York: Cambridge
These programs include board re- University Press, 1982); M.J. Vogel, The In-
Recommendation 2: treats, continuing education pro- vention of the Modern Hospital: Boston 1870-
A body of literature needs to be devel- grams in hospitals that trustees can 1930, (Chicago, Ill.: University of Chicago
Press, 1980); and S. Opdyche, No One Was
oped to support discussions of trustee attend, and hospitals’ distribution of Turned Away: The Role of Public Hospitals in
ethics, and ethics-related articles should materials to their trustees. New York City since 1900 (New York: Ox-
be included in various publications de- ford University Press, 1999).
signed for a trustee audience. 9. L.M. Salamon, America’s Nonprofit Sec-
References
tor (New York: The Foundation Center, no
The field of bioethics, and cognate date), 57-70.
1. Although the results of our research
disciplines such as medical sociology, will be generically applicable to some ex- 10. S.M. Shortell, R.R. Gilies, and K.J.
health services research, and manage- tent, we have chosen to focus on the special Devers, “Reinventing the American Hospi-
ment studies, have not given trustee circumstances of the trustee in a not-for- tal,” Milbank Quarterly 73, no. 2 (1995):
ethics the attention it deserves. Edi- profit setting because of the distinctive 131-60.
tors of bioethics and academic jour- moral and legal responsibilities that obtain 11. J.A. Alexander, “Hospital Trusteeship
in that setting. Trustees or directors of for- in an Era of Institutional Transition: What
nals should encourage publications profit hospitals will also benefit from the Can We Learn from Governance Research?”
on this topic, and researchers should ideas discussed in this report, but they will in The Ethics of Hospital Trusteeship, ed. Jen-
develop studies along these lines or not be its focus. Papers commissioned for nings et al.
build ethics issues into multidiscipli- the project, some of which are cited below,
12. The discussion in the following pages
nary projects. These publications may can be found in Bruce Jennings, Virginia
draws upon B.H. Gray and L. Weiss, “The
Ashby Sharpe, Bradford H. Gray, and Alan
not be read regularly by many indi- Role of Trustees and the Ethics of Trustee-
R. Fleischman, eds. The Ethics of Hospital
viduals who serve as trustees, but if ship: Findings from an Empirical Study,”
Trusteeship: Responsible Governance of the
and L. Weiss and B.H. Gray, “Hospital
first-rate articles are once published, Not-for Profit Hospital (Washington, D.C.:
Partnering, Sale and For-Profit Conversion:
they be reprinted and used in educa- Georgetown University Press, forthcoming
Trustees’ Responsibility and Perceptions in a
tional programs for trustees. Trustee 2003).
Time of Change,” both in The Ethics of Hos-
attention can also be called to ethical 2. We follow conventional usage in refer- pital Trusteeship, ed. Jennings et al. See these
ring to the members of the governing board chapters for further discussion about the
issues directly via publication in mag- of not-for-profit organizations as “trustees” methods and findings of this study.
azines or other publications that are instead of “directors,” which is used in the
13. B. Jennings, “Hospital Trusteeship
directed toward trustees, such as the for-profit sector. Moreover, when we use the
and the Ethics of Representation,” in The
American Hospital Association’s pub- term “trustee” in this report we refer not to
Ethics of Hospital Trusteeship, ed. Jennings et
lication, Trustee. trustees of not-for-profit organizations in
al.
general but specifically to a trustee of a not-
for-profit hospital. 14. R.H. Wynia, F. Margolin, and M.A.
Recommendation 3: Pittman, “The Role of Hospitals in the
3. See H.J. Goldschmid, “The Fiduciary
Community,” in The Ethics of Hospital
Financial support for research and edu- Duties of Nonprofit Directors and Officers:
Trusteeship, ed. Jennings et al.
cation on the ethical issues facing hospi- Paradoxes, Problems, and Proposed Re-
forms,” The Journal of Corporation Law 23, 15. D. Smith, Entrusted: The Moral Re-
tal trustees and executives should be de- no. 4 (1998): 631-53; reprinted in The sponsibilities of Trusteeship (Bloomington:
veloped to encourage excellent work in Ethics of Hospital Trusteeship, ed. Jennings et Indiana University Press, 1995). See also D.
this field. al. Smith, “Trustees and the Moral Identity of
the Hospital,” in The Ethics of Hospital
Foundations and government 4. On legal responsibilities of not-for-
Trusteeship, ed. Jennings et al.
profit boards, see D. Seay, “The Legal Re-
agencies concerned with health ser- sponsibilities of Voluntary Hospital 16. See E. Robilotti and D. Rosner, “The
vices and administration issues, quali- Trustees,” in The Ethics of Hospital Trustee- Trustees’ Dilemma: Hospitals as Benevo-
ty of care, patient’s rights, and the like ship, ed. Jennings et al.. lence or Business—Looking Back a Centu-
ry,” in The Ethics of Hospital Trusteeship, ed.
should devote more attention and re- 5. R. Stevens, In Sickness and in Wealth:
Jennings et al. Compare M. Schlesinger and
sources to the topic of hospital American Hospitals in the Twentieth Century
B.H. Gray. “A Broader Vision for Managed
trustees and trustee ethics. (New York: Basic Books, 1989).
Care, Part 1: Measuring the Benefit to
6. B.H. Gray, “The Changing Face of Communities,” Health Affairs 17, no. 3
Health Care,” in Philanthropy and the Non- (1998): 152-68; and “A Broader Vision for
Recommendation 4: profit Sector in a Changing America, ed. C.T. Managed Care, Part 2: A Typology of Com-
Hospitals and health systems should de- Clotfelter and T. Erlich (Bloomington: In-
diana University Press, 1999), 364-84.

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S23
munity Benefits,” Health Affairs 17, no. 5 19. D.D. Pointer and J.E. Orlikoff, Board 22. A.R. Kovner, “Fitting Board Informa-
(1998): 26-49. Work: Governing Health Care Organizations tion to Board Function,” in The Ethics of
17. W.F. May, “The Trustees of Non- (San Francisco: Jossey-Bass, 1999). Hospital Trusteeship, ed. Jennings et al.
Profit Hospitals: Dealing with Money, Mis- 20. A.J. Riddell and S. Hanson, “Inher- 23. V.A. Sharpe, “Patient Safety and the
sion, and Medicine,” in The Ethics of Hospi- ent Tensions: Administration Versus Not- Role of Hospital Boards,” in The Ethics of
tal Trusteeship, ed. Jennings et al. for-Profit Governance,” in The Ethics of Hospital Trusteeship, ed. Jennings et al.
18. This point may be most obvious Hospital Trusteeship, ed. Jennings et al. 24. J.J. Fins, “What Hospital Trustees
when a hospital is affiliated with a particular 21. See T.P. Holland, R.A. Ritvo, and Can Learn from Ethics Committees: An
religious tradition, but it is valid for hospi- A.R. Kovner, Improving Board Effectiveness: Essay on Pragmatism, Ethics, and the Gov-
tals with a secular history and mission as Practical Lessons for Nonprofit Health Care ernance of Health Care Organizations,” in
well. See C.J. Dougherty, “Ethical Dimen- Organizations (Chicago, Ill.: American Hos- The Ethics of Hospital Trusteeship, ed. Jen-
sions of Trusteeship on Boards of Catholic pital Publishing, 1997). nings et al.
Hospitals and Systems,” in The Ethics of
Hospital Trusteeship, ed. Jennings et al.

S24 July-August 2002/HASTINGS CENTER REPORT


A Model Workshop on Ethical Issues in
Not-for-Profit Hospital Trusteeship

Agenda
T his is a design for a four-hour workshop intend-
ed for those who serve as hospital trustees, hos-
pital executives, and health care professionals with an Registration and Coffee
interest in ethics and contemporary problems of
health care governance and management. Introduction—Workshop Moderator
Its presentational format alternates between ple- (plenary session, 20 minutes)
nary sessions and smaller break-out sessions. Both Define the problem, “Board service and trusteeship in turbulent times,” explain
types of sessions feature faculty-participant interac- the objectives of the workshop, give overview of program and process, intro-
tion and discussion. One break-out session is devot- duce speakers
ed to the discussion of a case hypothetical (based on
actual cases) that raises ethical issues for board mem- Trusteeship in turbulent times—Expert on boards of trustees and issues
bers. The workshop is designed both to convey infor- facing the health care system generally
mation concerning expert thinking about ethical and (plenary session, 50 minutes including discussion from the floor)
legal standards for not-for-profit hospital trustees and Review the present state of not-for-profit hospitals and the issues and pres-
to permit trustees and others to share their own per- sures facing trustees
spectives and experience. Its goal is to encourage and
enable trustees and hospital executives to discern Small group discussion of trustee experiences and perspectives
more clearly the ethical dimensions of their policy- (break-out session of no more than ten people, led by a facilitator; 40 minutes)
making and decisionmaking and to conduct board
operations and board business in a way that is atten- Trustees’ views—Present or former trustee
tive to the ethical responsibilities attached to the role (plenary session, 40 minutes including discussion from the floor)
of trustee. Begin with brief reports from each break-out session concerning the issues
they identified (15 minutes)
Resource Materials Speaker to present findings of an empirical study of trustee and CEO attitudes
and opinions of trustee duties, responsibility and functioning.1 These findings
can be used as a point of comparison with the ideas that surface in the break-
T he workshop is built around the analysis and
ethical framework presented in “Ethics and
Trusteeship for Health Care: Hospital Board Service
out groups

in Turbulent Times,” Hastings Center Report Special Ethical principles for hospital trusteeship—Expert on ethics
Supplement, July-August 2002. Reprints of this docu- (plenary session, 40 minutes including discussion from the floor)
ment may be photocopied or obtained from The Describe the principles and framework for ethical trusteeship and board func-
Hastings Center and either distributed at the work- tioning
shop or mailed to registrants prior to the workshop.
In addition, a PowerPoint presentation is available Small group discussion of an ethics case for trustees
from The Hastings Center that contains slides per- (break-out session with groups of no more than ten people each, led by a facili-
taining to each of the plenary presentations in the tator; 40 minutes)
model workshop. An alternate approach to this session is to have a panel of three or four
Optimal faculty requirements are four people: (1) trustees discuss the case in a plenary session and then open up the discus-
a moderator who can provide an overview of the is- sion of the case to the audience
sues, (2) someone knowledgeable about current aca-
demic research on hospital boards and trustee behav- Concluding session (plenary session, 20 minutes)
ior, (3) someone knowledgeable about the ethical is- Brief reports from the small groups on highlights of their discussions of the
sues in trusteeship and management and able to dis- case
cuss the ethical framework presented in the article
mentioned above and in other literature on the ethics Closing comments by workshop moderator
of trusteeship, and (4) a current or former not-for-
profit hospital trustee who can lead a plenary discus- 1. B. Gray and L. Weiss, “The Role of Trustees and the Ethics of Trusteeship: Findings from an
Empirical Study,” in The Ethics of Hospital Trusteeship: Responsible Governance of the Not-for Profit
sion of trustee views and attitudes.
Hospital, ed. B. Jennings, V.A. Sharpe, B.H. Gray, and A.R. Fleischman (Washington, D.C.: George-
town University Press, forthcoming 2003).

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S25
A Case Hypothetical for the Workshop

C ommunity General Hospital is a 300-bed urban hospital in a community that has


changed dramatically in the last twenty-five years. Created after World War II to
meet the health care needs of a white middle-class population, Community General
today serves a multicultural community of working poor minorities and uninsured re-
cent immigrants.
Community General has a proud history of service to its community, but its physi-
cal plant is old and in need of significant renovation. The hospital also has a proud tra-
dition of affiliation with a regional medical school, provides sites for education of stu-
dents, and has two accredited graduate medical education training programs in inter-
nal medicine and surgery. In recent years these residencies have been able to attract only
international medical graduates.
The chief executive of Community General will reveal at the board meeting today
that in the first quarter of this fiscal year there is a three-million dollar deficit and she
predicts a fifteen-million dollar shortfall for the year.

As a board member:
• Are you surprised by this revelation, given a re-engineering and downsizing exercise
last year that reduced personnel by 15 percent?

• What information do you need to begin to address this issue?

• What has been the impact of previous cost cutting measures on quality of care? Staff
morale? Community response?

• Can you articulate the “mission” of Community General?

• Do you see this as an ethical dilemma or only as a fiscal matter?


The CEO suggests three potential options to address the problem: close two
money-losing primary care clinics, each several blocks from the hospital; close the pe-
diatric inpatient service, which has a decreasing occupancy; or attract a group of three
interventional cardiologists away from a neighboring hospital by creating a new
catheterization laboratory which will cost two million dollars.

As a board member:
• How do the views of the community affect your decision?

• Will you consider either merging with another institution or closing?

• How do you interpret your duty to:


- fidelity to mission
- service to patients
- service to community
- stewardship of the institution

S26 July-August 2002/HASTINGS CENTER REPORT


Task Force Members

n William N. Hubbard, Jr., Chair n Alan R. Fleischman n Mary Pittman


Dean Emeritus Senior Vice President President
University of Michigan School of Medicine The New York Academy of Medicine The Hospital Research and Educational
Trust
n Vincent Antonelli n Livingston S. Francis American Hospital Association
Program Officer President and Chief Executive Officer
Division of Health and Science Policy Livingston S. Francis Associates n Kenneth Raske
The New York Academy of Medicine President
n Harvey J. Goldschmid Greater New York Hospital Association
n Jeremiah A. Barondess Professor of Law
President School of Law n Paul Rulison
The New York Academy of Medicine Columbia University Executive Director
Healthcare Trustees of New York State
n Henry Betts n Bradford H. Gray
Vice Chairman, Medical Director and Director n David Seay
Chief Executive Officer Division of Health and Science Policy Vice President, Secretary and Counsel
Rehabilitation Institute of Chicago The New York Academy of Medicine United Hospital Fund

n Irwin Birnbaum n Bruce Jennings n Virginia A. Sharpe


Chief Operations Officer Senior Research Scholar Associate
School of Medicine The Hastings Center The Hastings Center
Yale University
n Anthony Kovner n David H. Smith
n Stanley Brezenoff Professor Director
President Health Policy and Management Poynter Center for the Study of Ethics and
Maimonides Medical Center New York University Wagner School American Institutions
Indiana University
n Gerard Carrino n Patricia Levinson
Senior Program Officer New York, N.Y. n William C. Stubing
Division of Health and Science Policy President
The New York Academy of Medicine n Paula Lowest The Greenwall Foundation
Weil, Gotschal and Manges
n Edward J. Connors n Susan Waldman
President n William F. May Senior Vice President and General Counsel
Connors, Roberts and Associates Cary M. Macquire Professor of Ethics Greater New York Hospital Association
Southern Methodist University
n Strachan Donnelley n Linda Weiss
Director, Humans and Nature Program n Richard L. Menschel Senior Program Officer
The Hastings Center The Goldman Sachs Group, L.P. Division of Health and Science Policy
The New York Academy of Medicine
n Charles J. Dougherty n Linda Miller
Academic Vice President President Affiliations listed were current at the time of
Creighton University Volunteer Trustees of Not-for-Profit task force activities, 1997-99, and are for
Hospitals identification purposes only.
n Joseph J. Fins
Director of Medical Ethics n Ira Millstein
The New York and Presbyterian Hospital— Weil, Gotshal and Manges
Cornell Campus

SPECIAL SUPPLEMENT/ Ethics and Trusteeship for Health Care: Hospital Board Service in Turbulent Times S27
About
The Hastings
Center
T he Hastings Center addresses fundamental ethical issues in the areas of
health, medicine, and the environment as they affect individuals, com-
munities, and societies. With a small staff of senior researchers at the Center
and drawing upon an internationally renowned group of over 100 elected
Fellows for their expertise, The Hastings Center pursues interdisciplinary re-
search and education that includes both theory and practice. Founded in
1969 by philosopher Daniel Callahan and psychoanalyst Willard Gaylin, The
Hastings Center is the oldest independent, nonpartisan, interdisciplinary re-
search institute of its kind in the world. From its earliest days The Hastings
Center has understood that the moral problems arising from rapid advances
in medicine and biology are set within a broad intellectual and social conext.
The Center’s collaborations with policymakers, in the private as well as the
public sphere, assist them in analyzing the ethical dimensions of their work.

O R D E R I N F O R M AT I O N
For copies of this or other Hastings Center Report Special Supplements, write or call:
Membership Department, The Hastings Center, 21 Malcolm Gordon Road, Garri-
son, NY 10524-5555; (845) 424-4040; (845) 424-4545 fax; publications@thehast-
ingscenter.org; www.thehastingscenter.org.

About
T h e N e w Yo r k
Academy
of Medicine
T he New York Academy of Medicine, founded in 1847, is an independent
nonprofit institution committed to enhancing the health of the public
with a particular emphasis on disadvantaged urban populations. This mission
is fulfilled through research, education, and advocacy focused on under-
standing and eliminating the root causes of poor health. The research agenda
includes epidemiologic, health policy, and public health studies of all the
major contributors to the poor health status of underserved populations. In
the area of education, the Academy convenes an array of conferences and
symposia on health issues, offers continuing medical education opportunities
for professionals, and provides health education training for teachers. The
landmark Academy building contains one of the world’s largest privately
owned medical libraries, which is open to the public. As a unique academic
forum in which all constituencies of the medical and health care community
can convene and collaborate as equal partners, the New York Academy of
Medicine attracts renowned scholars, analysts, physical and social scientists,
medical practitioners, and community leaders from around the world. These
collaborations seek to enhance knowledge, strengthen public health organi-
zations, advance clinical practice, and promote scholarship in medical and
health affairs.

S-ar putea să vă placă și