The personal and professional decision-making process is omnipresent, comprising choices from the trivial to the profoundly transformative. These judgments might be made unconsciously in personal or explicit professional situations. Ethics are crucial to professional decision-making, especially in healthcare organizations (HCOs). This is crucial in healthcare because even little departures from norms may harm patients. This paper aims to examine salient research on ethical criteria in decision-making within HCOs and underline pivotal factors to ensure ethically sound decision-making in these settings. This analysis employed a literature review methodology. Organizational management requires decision-making to meet patient demands and improve community health. An educated investigation, a clear flow chart, and a well-structured ethical approach may lead to better answers and morally sound decisions. Establishing an HCO ethical committee may also prevent hasty choices by following a procedure. It also allows post-hoc decision evaluation to measure robustness and influence on stakeholders, including health providers. This examination may discover decision flaws and risks, helping resolve ethical difficulties. Executives to staff members make ethical decisions in HCOs, which vary by scientific subject, experience, talents, and company culture. Maintaining ethical standards in decision-making is a complex and continual undertaking that requires a thorough grasp of many aspects.
Williams, (2015) comprehensive examination of the moral judgments unequivocally asserts that health-care workers, from frontline staff to administrative personnel, regularly encounter moral dilemmas (Nel-son, 2015). Clinicians may grapple with challenges such as disputes regarding the withdrawal or ter-mination of life-sustaining measures or breaches of patient confidentiality. On the other hand, executives might wrestle with organizational friction over providing essential yet costly services or navigate the intricacies of an efficient admin-istrators aggres-sive conduct. Moreover, divergent codes of conduct, moral positions, or the personal principles within a single institution or across the industry can com-pound these dilemmas. The Ethics Manual of the American College of Physicians and the Code of Ethics of the American College of Healthcare Exe-cutives serve as the exemplary guidelines in such contexts ( Faisal et al., 2023; Executives, 2016).
The challenge for healthcare leaders and all involved parties lies in discerning the appropriate course of action once an ethical conflict is the recognized. A systematic procedure can enhance the analysis, the culminating in a morally acceptable resolution. By adhering to a systematic procedure, clinicians, CEOs, or members of an ethics committee can reduce the likelihood of the impulsive judgments being made without sufficient contemplation or the justification. Contrariwise, although time-intensive, con-sistently employing a well-conceived process when tackling ethical dilemmas can generate morally justifiable outcomes instead of the reflexive responses. This method allows for a more productive appli-cation of ethical principles, institutional values, and policies to ethical disputes. Furthermore, it fosters the dialogue among individuals with varying pers-pectives on the ethical dilemma.
Review of Literature
Aslan et al. (2013) underscore the indispensability of decision-making within business management. From planning to control, decision-making forms an inte-gral part of the organizational management. This is particularly relevant for healthcare organizations, which must make informed decisions to adequately cater to patient needs and promote community health (Aslan et al., 2013). Williams, (2015) research contends that healthcare executives and stakeholders are tasked with discerning the appropriate course of action upon encountering an ethical paradox. A systematic approach can yield an effective and morally acceptable response. By adhering to a meti-culously constructed process, clinicians, CEOs, and members of ethics committees can sidestep impe-tuous decisions. Even though it might be time-consuming, persistently applying a well-designed ethical strategy can yield ethically defensible out-comes instead of default reflexive responses. This approach assists in resolving ethical dilemmas by applying ethical principles, institutional values, and policies. Moreover, it stimulates discussion among individuals holding differing viewpoints (Nelson, 2015). This is mirrored in the argument in "Ethical Decision-Making for Healthcare Executives" (2016), which suggests that healthcare leaders must acknow-ledge and navigate the growing array of complex ethical concerns they encounter. However, this cannot be achieved independently or without a ro-bust decision-making process incorporating many perspectives. An organized decision-making process can aid leaders, workers, and stakeholders in disco-vering solutions to ethically challenging circums-tances ( Zaman et al., 2021, Executives, 2016).
Complementing this, Bruning and Baghurst, (2013b) emphasize the importance of vision and ideals in conjunction with the appropriate modelling of ethical behaviour. Relationships can become strained when healthcare professionals, patients, and payers diverge from this shared goal. The absence of a forward-moving shared vision can lead stakeholders to the stagnate in the past and overlook learnings from ethical behaviour. Hence, it becomes paramount for healthcare leaders to identify, articulate, and rein-force the benefits of collaboration amongst diverse the healthcare networks, including establishing the ethical boundaries within which decisions are made (Bruning & Baghurst, 2013). When decisions adhere to ethical principles, collaboration is fostered, and the implications of a lack of collaboration become more apparent. As physicians and the patients colla-borate on care decisions, focusing on shared values while acknowledging and respecting differences in perspective, consensus can be reached. This, in turn, is bound to culminate in improved health outcomes.
The Role of Decision-Making in Healthcare
Aslan et al. (2013) emphasized that decision-making is ubiquitous in life, permeating personal exp-eriences and the professional roles. Decision-making encompasses a wide range of topics, such as salary determinations, procedures, market activities, poli-tical affiliations, and betting, areas that engage disciplines as diverse as politics, psychology, system analysis, and economics (Aslan et al., 2013). This process of decision-making is equally critical to the operation & governance of a company or organiz-ation. Indeed, decision-making permeates every facet of management, starting from the initial planning stage and extending through to the control phase. Therefore, the decision-making is an indispensable element of efficient organizational administration. Concurrently, the decision-making within healthcare organizations is a vital function, enabling these organizations to meet patient needs and expectations, thereby enhancing the community health. One can illuminate the decision-making process by con-sidering two principal constituents: the patients and the management. In other words, the decision-making process within the healthcare organizations holds paramount significance as it directly impacts patient lives and facilitates an effective management system. By acknowledging the criticality of this process, healthcare organizations can better navigate the challenges and opportunities inherent in their important work (Fig. 1).
Ethical Decision-Making
Ethical decision-making is the process of generating & implementing ethical decisions. Ethical decisions tend to uphold legal and professional standards and respect relevant stakeholders, including co-workers, supervisors, subordinates, customers, investors, and society (DuBois, 2008).
Fig. 1: A visual representation of the decision-making process in healthcare organizations.
Ethical Decision-Making at the Executive Level
When personal, the organizational, professional, and societal values clash, healthcare executives are the tasked with making ethical decisions. Crucial consi-derations in this decision-making process encompass justice, autonomy, beneficence, and non-maleficence principles. The complexity of the ethical issues in healthcare organizations, clinical, organizational, and societal, has increased due to concerns surrounding equal access and cost, patient safety, quality, value-based treatment, disclosure of the medical errors, allocation of scarce resources, mergers and acquis-itions, financial and other resource restrictions, the advanced medical treatment innovations, and end-of-life decision-making. Healthcare leaders face the increasingly difficult task of identifying and addres-sing these ethical challenges. However, this cannot be accomplished in isolation or without a robust de-cision-making process considering diverse view-points. Through a structured the decision-making process, leaders, staff, and stakeholders can navigate ethically challenging situations effectively. In con-clusion, the role of the healthcare executives is multifaceted and instrumental in numerous aspects. They are responsible for the developing a systematic ethics decision-making process that the reinforces ethical clinical and administrative practices, policies, and decisions aligned with the organizations mission & values. They showcase the organizations commit-ment to its ethical mission or value statements. In their professional conduct, they embody the ethical decision-making and represent the organizations emphasis on ethics. Additionally, they initiate edu-cational programs for the board members, senior leadership, staff, physicians, and other relevant groups, including the wider community. These pro-grams aim to educate about the organizations ethical standards and the global issues that necessi-tate ethical decision-making in the contemporary health-care landscape (Executives, 2016).
Ethical Decision-Making at the Practitioner Level
Bruning and Baghurst, (2013b) elucidate in their article that while a common goal may ostensibly unify the healthcare sector, the distinct objectives of its diverse stakeholders have led to divergent pers-pectives on the best approach to realize that goal. Tensions might exist between physicians desire for autonomy in the treatment decisions and insurers objectives to reduce healthcare costs. Similarly, a payers decision not to fund a controversial drug could conflict with a patients desire to use it for treatment. Disputes between the patient and practi-tioner may stem from the patients emotional state or knowledge disparities. The shared vision provided by healthcare executives for these partnerships must be rooted in ethical norms and principles. Without the correct modelling of the ethical behaviour, the essence of vision and values dissipates. Relation-ships risk deterioration when providers, patients, and payers demonstrate behaviours inconsistent with the shared vision. Stakeholders are confronted with a difficult choice between dwelling in the past without learning from ethical behaviour or progressing to construct and model a shared vision (Bruning & Baghurst, 2013). Keeping this in mind, healthcare leaders must identify, articulate, and reinforce the benefits of collaboration among various healthcare networks. This process involves defining the moral parameters within which decisions must be made. Collaboration is nurtured when decisions align with ethical principles and a deeper understanding of the repercussions of a lack of collaboration is developed. By emphasizing commonalities and acknowledging and appreciating the differences in the viewpoints, physicians and patients can establish consensus and mutual respect when the making collaborative care decisions. This is undoubtedly conducive to enhan-ced care outcomes.
In conclusion, defining ethical standards in health-care decision-making involves several vital stages. Firstly, its essential to identify the ethical principles guiding decision-making in the healthcare, including autonomy, beneficence, non-maleficence, justice, and respect for persons. Next, stakeholders involved in the healthcare decision-making, such as patients, healthcare providers, administrators, policymakers, and the general public, must be identified. The sub-sequent step involves determining how the ethical principles apply to these stakeholders. For example, one might consider the application of the autonomy principle to patients versus healthcare providers. A set of criteria based on the initially identified ethical principles, which respect the interests and values of the involved stakeholders, needs to be developed to assess the ethical implications of various healthcare decisions. Finally, these criteria should be used to evaluate healthcare decisions to determine the most ethical action.
Theoretical Models of Ethics in Healthcare Organizations
According to Guidolin et al. (2021b) the COVID-19 pandemic has substantially strained global healthcare resources, compelling providers to make unprece-dented resource allocation decisions. Despite a year of studying COVID-19, their ethical approach to resource allocation has remained consistent. During the pandemics initial wave, they reduced overall clinical activity to accommodate COVID-19s expec-ted needs, leading to resource wastage and ineffici-ency. Consequently, they aimed for more thoughtful & ethical decision-making in preparation for the second wave. Their article introduces a tool for the ethical and fair decision-making during resource constraints. To ensure consideration of a wide array of stakeholder perspectives, they convened a multi-disciplinary team, the clinical activity recovery team, to create, develop, and implement this tool. This team established institutional goals and inte-grated them with the procedural values, substantive ethical principles, and decision-making criteria using a vari-ant of the well-known ethical framework, account-tability for reasonableness. As a result, they deve-loped an incremental, semi-quantitative, ethical decision-making tool that can be applied to resource allocation issues, yielding fair and ethically justify-able decisions. This tool can be beneficial at insti-tutional & departmental levels. To guide decision-making, they utilized an ethical framework based on a fair, transparent, deliberative process known as "accountability for reasonableness." This framework informed the development of an ethical decision tool proactively deployed at various levels of the clinical activity decision-making during the pandemics 2nd wave.
Furthermore, another model presents the decision-making process as a series of "filters" to highlight the associated ethical issues and consequences. When decisions are seen as "business" rather than "ethics issues," it is easier to overlook principles, potentially leading to the ethical breaches. Therefore, pausing at key points to address these filters is crucial, ensuring that embedded ethical consider-ations are accounted for. These factors are encap-sulated in the mnemonic PLUS: Policies (conformity with my organizations policies, procedures, and guidelines), Legal (compliance with existing laws and regulations), the Universal (alignment with my organizations established guiding principles and values), & Self (consistency with my sense of the justice, decency, fairness). The PLUS filters fun-ction as integral parts of decision-making process, enabling the decision-maker to assess whether the ethical aspects of the decision are illuminated, addressed, or satisfied (Guidolin et al., 2022).
Empirical Studies on Ethical Decision-Making in Healthcare Organizations
Roshanzadeh et al. (2020) emphasized the imper-ative for nursing managers to adhere to ethical norms in decision-making processes to fulfil the aims of the healthcare system. They asserted that simple ethics awareness is insufficient in complex and challenging healthcare environments; the managers must exhibit sensitivity when the making ethical decisions. Their study analyzed the experiences of nursing managers, specifically how they weigh ethical considerations in their decision-making processes. The findings sug-gested that the ethical awareness of the nursing managers facilitates optimal choices through a mix of foresight, commitment, and assertiveness. Uphol-ding high moral standards ensures that healthcare ethics are respected across the board. However, despite most managers commitment to the ethical conduct, the study concluded that a training program focusing on management and ethical concepts is necessary to broaden their perspectives. Addressing individual and organizational ethical barriers could enhance managers assertiveness, improving their capacity to make ethical decisions (Roshanzadeh et al., 2020). Moreover, Wendt et al. (2020) discussed the challenges healthcare organizations face as decision-makers grapple with integrating new tech-nologies and meeting increasing patient demands for equitable access to medical care. They analyzed two decision-making processes related to the vascular surgery in Norway from 2007 to 2019. Both proce-sses were time-consuming and costly and resulted in minor modifications to the delivery of the vascular services. Notably, both local and national actors managed to bypass healthcare planners. They found that local decision-making often became a strategic game between various departments and professional sectors, while regional decision-making devolved into a political process. This study sheds light on the complexities of decision-making in fields charac-terized by rapidly evolving technology, novel treat-ment alternatives, and increasing the demands for equitable resource distribution (Wendt et al., 2020).
Relationship between Ethics and the Decision Indicators
In healthcare organizations, ethical principles and values such as "autonomy," "beneficence," "non-maleficence," and "justice" often serve as guidelines in decision-making. In contrast, decision indicators are metrics used to analyze the impact of decisions on an organizations performance, thereby facili-tating the evaluation of the decision consequences. Examples of decision indicators in healthcare might include patient satisfaction rates, readmission rates, & the overall financial performance of the organiz-ation, among others (Executives, 2016). With this in mind, several key elements need to be considered when formulating criteria that bridge ethical signs and decisions:
1) What are the most significant ethical concepts and values to consider in the decision-making process within healthcare organizations?
2) How can these ethical principles be reframed as decision criteria to guide decision-making?
3) What decision indicators are most relevant when measuring the impact of ethical decision-making on organizational performance?
4) How can potential conflicts between ethical considerations & decision indicators be iden-tified and resolved, and what could be examples of such conflicting decision indicators?
Challenges in the Ethical Decision-Making in Healthcare
Dennis, (2022) in her article articulated that nurses frequently grappled with ethical challenges that the originated externally and were manifested as moral uncertainties or the world-imposed dilemmas. These dilemmas occurred when external factors imposed an ethical problem with no obvious resolution. Under these circumstances, nurses had to the comply with external guidance in light of the situation. Policies, administrative decisions, and managerial directives could place unwelcome constraints on the nurses choices. The then nursing crisis, characterized by staffing shortages, had influenced care decisions, often leading to the moral ambiguity that affected healthcare during the pandemic (Dennis, 2022).
Similarly, Gerritse et al. (2022) underscored that the ethical difficulties and normative diversity were potentially inescapable. Unaddressed ethical challen-ges could significantly burden the client-clinician relationship & affect decision-making, care process-ses, ultimately, the quality of care. This emphasized the need for increased understanding & sensitivity towards the inherent ethical problems, normativity, and contextual uncertainties in the decision-making. They proposed that effective, shared decision-making required collective identification and man-agement of ethical issues and an ongoing, thoughtful discussion among clients, thera-pists, and multidisci-plinary team members. Clinical ethics could have provided valuable tools to the promote more openly debated and justified shared decision-making (Ger-ritse et al., 2022). Comple-menting these views, Hoffmann et al. (2018) stressed the importance and complexities of shared decision-making in older adults with multimorbidity. They argued that careful and collaborative decision-making was key to deli-vering patient-centred care, necessitating the identi-fication of patients concerns, priorities, & prefer-ences, followed by the patient-centred goal setting. Shared decision-making involves discussions about treatment options, benefits, risks, and the patients preferences, leading to a joint decision about the way forward. While shared decision-making could be implemented with or without the decision aid, it required certain motivations and skills, especially for singular conditions (Hoffmann et al., 2018).
This literature study examined scholarly literature on ethical decision-making in healthcare institutions. Using a flexible strategy, we searched the numerous electronic databases for relevant English peer-reviewed journal papers. We identified major themes and ethical principles in the collected literature and examined their applicability in healthcare decision-making via systematic screening and data capture. Quality evaluation was not done since this review was generic. The results are combined thematically and presented narratively to illuminate ethical factors impacting healthcare organization decision-making and the suggest further study. Ethics were strictly observed throughout the review.
Recommendations for the Implementing Ethical Decision-Making in Healthcare
Tannahill and Douglas, (2014) argued that health organizations and policy-makers must make critical decisions on protecting and promoting population health by advocating for ethical standards. These ethical standards, defined as guiding principles, mirrored the organizations mission and core values (Tannahill & Douglas, 2014). Gerritse et al. (2022) added to this discourse, mentioning respondents ethical dilemmas and norms focused on separating & defining decisional responsibilities and boundaries, negotiating decision-making within a multidisci-plinary team, and managing varying timelines (Ger-ritse et al., 2022). Roshanzadeh et al. (2020) under-scored the necessity of expanding insights through a training program emphasizing professional manage-ment and ethical standards. They further posited that addressing ethical obstacles at both personal and organizational levels could enhance the managers assertiveness, facilitating their ability to make ethical decisions (Roshanzadeh et al., 2020).
Case Study
Treatment of Cancer Patients During the SARS-CoV-2 Pandemic
In the wake of the SARS-CoV-2 pandemic, health-care professionals faced the significant difficulties providing routine care to the patients with severe illnesses. The situation was especially challenging for treating cancer patients due to their increased vulnerability and the immunosuppressive effects of both cancer and its treatments, which heightened the risk of infections and severe complications. The potential for the cancer treatment interruptions & discontinuation and the looming possibility of the rationing high-demand healthcare resources during a global health crisis added to these complications. This scenario demanded a need to protect cancer patients from contracting SARS-CoV-2 infection during their routine care. Al-Tabba et al. (2020) examined the ethical problems decision-makers and medical professionals faced when treating cancer patients during the SARS-CoV-2 pandemic. The challenges included setting triage criteria for non-infected cancer patients, equitably allocating scarce healthcare resources between cancer patients and SARS-CoV-2 patients, prioritizing SARS-CoV-2 treatment or vaccination for cancer patients and non-cancer patients, patient-physician communication on issues like end-of-life and do-not-resuscitate (DNR) orders, and shifting doctors priorities from treating their cancer patients to the managing critically ill patients (Al-Tabba et al., 2020). In such extra-ordinarily challenging circumstances, no decision could be taken lightly. Different ethical principles could yield varying scenarios and outcomes. Finally, the experiences of the King Hussein Cancer Facility (KHCC), the regions sole independent comprehen-sive cancer facility, were briefly discussed.
Personal Perspective on Ethical Decision-Making in Healthcare
Navigating ethics in decision-making is undeniably complex, a fact the researcher has personally experi-enced in my progression through the ranks of a healthcare organization. From being fresh graduates without experience to the eventually assuming man-agerial responsibilities for multiple sections and staff, researchers have been exposed to decision-making across different roles and responsibilities within the healthcare structure. When faced with ethical dilemmas during my professional journey, the researcher has learned to evaluate significant and critical decisions, reflecting on these issues in my current position. As one rises to a decision-making level, one is expected to make decisions based on various workplace scenarios involving colleagues and patients. Furthermore, the ethical standards are a moral compass that should guide all our decisions. When faced with a decision, its vital not to com-promise these standards. Once a decision is made, its equally important to stand by it, under-standing the potential harm it could cause to a third party despite being authorized to make decision. In con-clusion, the application of ethics, be it in personal or professional life, remains the same. When making decisions, it is essential to ensure that every ethical aspect is considered to avoid causing harm or wor-sening someones condition due to neglect of these ethical considerations. Every decision carries weight, and taking each one seriously is crucial to upholding ethics in every facet of our professional conduct.
Navigating ethical dilemmas can be an arduous task for leaders in the healthcare industry, as well as all other stakeholders involved. Implementing a system-atic strategy can enhance the analysis and contribute to developing a solution that aligns with the ethical values upheld within the community. A substantial body of research underscores that decision-making is one of the most critical aspects of business man-agement. Both general management and organiz-ational leadership necessitate astute decision-making executed via appropriate methodologies. Healthcare organizations, hence, bear the responsibility of the making decisions that cater to patients needs and enhance the well-being of the caregivers. Healthcare executives and other decision-making personnel should evade impulsive decision-making and instead adhere to a systematic decision-making process. Additionally, an in-depth analysis of the surrounding circumstances of the decision can yield more fitting outcomes that are ethically defensible, align with the institutions values and practices, and are receptive to various perspectives. In conclusion, to define ethical standards in healthcare decision-making, ethical principles such as autonomy, beneficence, nonmale-ficence, justice, and respect for persons should guide the process. These principles stand as commendable indicators of ethical concepts. On the other hand, decision indicators are metrics used to assess the impact of decisions on an organizations perfor-mance. Moreover, involving stakeholders such as patients, policymakers, administrators, and health-care providers in the decision-making process can lead to the development of a set of criteria that can be utilized to evaluate the ethical implications of various healthcare decisions.
I express my deepest gratitude to the International American University community for supporting to the successful research work.
Authors do not have any conflict of interest.
Academic Editor
Dr. Abduleziz Jemal Hamido, Deputy Managing Editor (Health Sciences), Universe Publishing Group (UniversePG), Haramaya, Ethiopia.
International American University, United States.
Ghonimat I., and Aburashideh H. (2023). Ethical criteria for decision-making within healthcare organizations, Eur. J. Med. Health Sci., 5(6), 186-193. https://doi.org/10.34104/ejmhs.023.01860193