The pre-conditions for "building capacity" in an ethics program.

Most organizations and/or their sub-units like ethics programs want to acquire the knowledge, skills and other resources needed to achieve their goals efficiently and effectively. Thus, they want to acquire or develop needed "capacity." But there are pre-conditions to building capacity that are often overlooked or forgotten, but which nevertheless, must be in place before capacity can be developed. This essay identifies these pre-conditions and discusses why they are necessary before attempts are made to enhance the capacity of any ethics program. The essay closes by offering a series of questions that ethics program leaders/and or members can asked themselves to assess whether or not these pre-conditions exist.

The Rashomon effect: organization ethics in health care.

The Academy-Award winning 1950 Japanese movie Rashomon depicts an incident involving an outlaw, a rape or seduction of a woman, and a murder or suicide of her husband. A passer-by, who is also the narrator, explains how the story is told to officials from four different perspectives: that of the outlaw, the woman, the husband and himself. The four narratives agree that the outlaw, wandering through the forest, came upon the woman on a horse being led by her husband; the outlaw tied up the husband, sex took place between the woman and the outlaw in front of the bound husband, and the husband was found dead. The narratives do not agree on how these events occurred or who killed the husband. The outlaw contends that consensual sex occurred between him and the wife, and he claims to have killed the husband. The wife depicts the sex as rape and claims that because of her disgrace she killed her husband. The husband, through a medium, says that the sexual act began as rape and ended in consent, and that in shame, after being untied by the outlaw he killed himself. The passer-by's story agrees with the husband's account of the sex and the bandit's account of the murder. Because the passer-by is also the narrator of the film, we tend to believe his version. But what actually took place is never resolved.

Stakeholder expectations in practice-based medicine.

Competitive pressures are forcing physicians from solo practice into new organizational structures. These new structures and the technologies supporting them have generated suggestions for improving medical practice. This article examines the unspoken assumption often accompanying these suggestions that practice improvement can come about through a closer alignment of the practice's goals and values with its stakeholders' expectations. Because conflict among competing goals is inevitable in a resource-scarce environment, an important question for each practice, and for each individual physician in a practice, is how to adjudicate conflicts of value when the goals of the practice appear to collide. This essay concludes with a proposal for an adjudicating process to help resolve these conflicts in practice-based medicine.

Total quality management and the silent patient.

This essay examines the impact of the imposition of businesses techniques, in particular, those associated with Total Quality Management, on the relationships of important components of the health care delivery system, including payers, managed care organizations, institutional and individual providers, enrollees, and patients. It examines structural anomalies within the delivery system and concludes that the use of Total Quality Management techniques within the health care system cannot prevent the shift of attention of other components away from the enrollee and the patient, and may even contribute to it. It speculates that the organization ethics process may serve as a quality control mechanism to prevent this shift and so help eliminate some of the ethically problematic processes and outcomes within the health care delivery system.