How ethical questions are treated merits look

Dr. Jeff Bishop said health-care workers have to deal with such ethical dilemmas every day. Sometimes they are easy to spot, but they're often more subtle than the abortion example.

"There are things in a person's own moral belief system and their own understanding of moral norms that he or she feels like they cannot violate," said Dr. Bishop, assistant professor in the department of internal medicine and the Ethics in Science and Medicine program at the University of Texas Southwestern Medical Center at Dallas.

Health-care workers should look at how their organization is set up to deal with these complicated questions, said Dr. Mark Pastin, president of the Council of Ethical Organizations in Alexandria, Va.

Open workplace debates about ethical issues aren't as common as they used to be, he said.

"The history of these ethical issues is a strange one," Dr. Pastin said. "Twenty years ago, these kind of discussions were more open than they are now. But health-care organizations became fearful of these conversations ... because of legal and liability issues."

He and other ethical experts recommend that employees investigate the following areas when they go to work for a health-care organization:

Administrative support. Organizations that are committed to following the rules will pay more than just lip service to ethical issues. Find out if there is a full-time officer overseeing integrity, ethics and compliance, Dr. Pastin said.

Many accrediting agencies require that hospitals appoint boards or use other methods to deal with ethical issues and grievances. But sometimes these devices exist more in theory than in practice, said Leah Curtin, a former editor of Nursing Management magazine who now publishes the online health-care newsletter CurtinCalls (www.curtincalls.com).

"Look at how often it [the ethics board] convenes, who is on it and if it actually considers cases," Ms. Curtin said. "If it's just window dressing ... then it won't do much good."

Code of conduct. Read the employee handbook to find out the official policy for reporting an ethics violation. "You want to find out if there is an anonymous way to do that as well," Dr. Pastin said.

Reputation. "Talk to other employees and find out if they are fearful of HR [human resources] or personnel," Dr. Pastin said. "In a bad environment, they are seen as ax men for management. In good places, they are seen as advocates for employees."

History. Check news accounts or accrediting agency reports to find out if a hospital has been repeatedly cited for infractions.

"If you find those things, see if they are willing to discuss them," Dr. Pastin said. "It may be technical thing such as billing. Find out if they are open and honest in dealing with that."

Finances. Ask to look at the financial statements. "Many hospitals are losing money today, but they shouldn't be secretive about it," Dr. Pastin said.

Retaliation. Hospitals should make sure that employees will not be hurt for reporting problems, Dr. Pastin said.

He said he has been surprised by surveys in which health-care workers say that they would not report a co-worker's error.

"They were equally afraid of fellow employees as much as administration," Dr. Pastin said. "This is a very unfortunate work environment. They are very fearful of one another."

Practices. Certain routines can call a hospital's integrity into question, Dr. Pastin said.

For example, overloaded nurses often can't keep up with patient charts, which are supposed to be updated as soon as care is administered.

"But sometimes nurses are asked not to log overtime, so they sign off, and on their own time they chart," Dr. Pastin said.

Such hospitals are basically forcing the nurses to lie or risk having their whole unit audited if they tell the truth, he said.

Turnover. Even in the low-unemployment economy, high turnover indicates that something is wrong, Ms. Curtin said.

Try to determine the revolving door's cause, she said. "Just because a place is not a good place to work, that doesn't mean it's not ethical," she said. "It may just be nasty."