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SPECIAL SUPPLEMENT
July-August 2002
ETHICS AND
TRUSTEESHIP
FOR HEALTH CARE
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.
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
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.
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-
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.
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
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:
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.
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.
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
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-
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-
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.
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
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 has been the impact of previous cost cutting measures on quality of care? Staff
morale? Community response?
As a board member:
• How do the views of the community affect your decision?
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.