1.

Background of the Ethical Problem

Ethical problems in managements are complex because of the extended consequences,

multiple alternatives, mixed outcomes, uncertain occurrences and personal implications.
Ethics has been generally defined as the principles of morally acceptable conduct of
individuals. We define ethics as and individuals personal beliefs about right and wrong
behavior. Although this simple definition communicates the essence of ethics, three
implications warrant additional consideration.
Professional Ethics concerns the moral issues that arise because of the specialist
knowledge that professionals attain, and how the use of this knowledge should be
governed when providing a service to the public. It designates the moral values that a
group of similarly trained people develop to control their performance of a task or their
use of resources. People internalize the rule and values of their professional culture just
as they do those of their society. The reflexively adhere to professional rules and values
when deciding on how to behave. (Ho Jo Ann & Tee Keng Kok, 2013)
Some organizations have many groups have many groups of professional employees
nurses, lawyers, researchers, doctors and accountants whose behavior is, governed
ethics. Professional ethics helps shape the organizations culture and determine the values
its members use in their in dealings with other stakeholders. Most professionals groups
are allowed to enforce the ethical standards of their profession. Doctors and lawyers, for
instance, can be banned from practicing if they violate professional rules.
In view of discussing the prime subject matter and the main objective of this assignment,
I have narrowed my scope to Nursing Ethics. Nursing ethics has often been viewed as a
subset of biomedical ethics along with medical ethics (Fry, 1989; Yeo, 1989). Yet there is
a growing recognition that nursing has its own distinct ethical commitments through
ethics research in nursing. This research has focused primarily on studying nurses moral
reasoning and the relationship between moral reasoning and ethical practice.

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For example, I would like to relate this discussion to one of the renowned moral
reasoning studies in nursing that was pioneered by Lawrence Kohlberg. Most of the
early nursing studies were based on Kohlbergs theory of moral development (1981).
He theorized that the moral development of each individual occurs in a series of six
stages which occur in a invariant sequence, each building on the other.
In Kohlbergs view, the pinnacle of moral development reached at stage six entails an
objective view of justice based on abstract and universal principles. He also held that not
everyone reaches the final stages of the hierarchy depending upon factors such as the
individuals level of education. Kohlberg grouped his six stages of development into three
levels as summarized below (Kohlberg, 1981; Miller, 1984):
Level 1

Pre-conventional: in which external rules determine right and wrong

action.
Stage 1: Punishment-obedience orientation, in which the goal of behavior
is to avoid punishment
Stage 2: Instrumental-relativist orientation, in which the goal of behavior
is self-gratification

Level 2

Conventional: where pleasing others and upholding the social order

through conformity to expectations is most important
Stage 3: Interpersonal concordance orientation, in which the goal of
behavior is pleasing others upholding the social order
Stage 4: Law and order orientation, in which the goal of behavior is
upholding the social order

Level 3

Post-conventional: in which moral judgments are based on the

autonomous, rational application of universal rules and principles
Stage 5: Societal consensus orientation, where the goal of behavior is to
develop and uphold social contracts, laws
Stage 6: Universal ethical principle orientation, in which the goal of
behavior is upholding justice and human rights

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The aim of this nursing studies generally were to measure the maturity of nurses moral
reasoning in comparison with the standards established by Kohlberg, and to examine a
number of variables that might affect subjects scores such as age, educational
background. But neither nurse administrators nor first-line managers have been the focus
of much research.
There are, however, some studies of nurse executives and interest in their ethical behavior
seems to be increasing. These studies are highly relevant to my proposed investigation for
two reasons. First, because the ethical behavior of nurse administrators can be expected
to directly affect first-line managers, and second, because it seems likely that they
experience some of the same conflicts s their managers although from a somewhat
different vantage point. (Armstrong & Whitlock, 1998)
Therefore, the ethical dilemma that I want to elaborate based on the requirement of this
assignment involved one case. This case happened at my workplace in Company A
since we moved from the old building at Kingfisher, Likas to the new headquarters at
Jalan Damai, Luyang.
1.1

Caught Between Cost and Care

Several participants related stories of ethical dilemmas in which they felt torn between
their care and concern for either patients or staff and their obligations as managers to
support institutional goals. Containing or reducing personnel costs was the common
denominator triggering many of these quandaries.
For example, I related an experience that occurred shortly after I assumed a new
management position on a busy medical-surgical unit. Although I had been in a
managerial role for several years, this experience had been in a specialty service in which
all of the staff was experienced registered nurses. I described what happened soon after I
assumed my new role.

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So my dilemma came very shortly after I got into this position, in that we had about
six new grads that we had on board, and one of my very first directiveswas to let any
of those go that we could, quickly, because it was getting close to their three month
probation time and we did not have any more moneys to put into them if we were going
to have to extend orientations
It was very difficult for me to move so quickly from being a manager who had always
mentored and supported my staff to one who now had to choose which staff members
would not continue to be employed. I had moved into this new position just as the
hospital census was dropping and the full time staff was being required to take time off. It
looked as if some of them would lose their jobs if nothing was done.
I was faced with the difficult dilemma of choosing who among the six new graduates
would be let go, and I used all the resources available for me in making the decision. I
talked at length with the unit preceptors, had multiple conversations with human
resources, and looked at very aspect of each new graduate performance. In the end, there
was one who was identified as not performing as well as the others and not yet ready to
function independently.
My reason is I tried to look at all aspects of her care. And although she didnt do anything
wrong, she was very tentative. She asked a lot of questions. She didnt have the whole
picture of the patient, the whole system. She couldnt focus very well on what needed to
be done. So it certainly was not without cause. It was just that any other time she would
have been salvageable.
Reflecting back on these events is still painful for me, and I cried as I recalled the
afternoon I told this new graduate that she would not be offered continued employment. I
described my feelings about that day,
the ethical [dilemma] for me was that I was forced into that situation, to have to
terminate somebody, although they really, truly didnt deserve it. And what that would

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do to her and her future career. That was so traumatic for me because I feltshe didnt
see it coming. It was just hard for me to do that to her.
Although this story is not typical of my everyday practice, the narrative does provide us
with insight into the more common place experience of nurse managers. Being in the
middle, means having dual ethic commitments that have an ever-present and often
unnoticed influence on my behavior.
My concern and caring for the staff is embedded in my view of what it means to be a
moral manager, a part of me understanding of goodness. However, being a manager
also entails an ethical obligation to support the goals of the institutions and to comply
with directives given by my administrative superiors. This dichotomy is an ever-present
fact of my work world.

2.0

Classification & Analysis of The Problem as an Ethical Problem in

Management

2.1

Most Ethical Decisions Have Extended Consequences

The results of managerial decisions and actions do not stop with first-level consequences.
Rather, they extend throughout society, and that extension constitutes the essence of
ethical arguments: the decisions of managers have an impact upon others, both within the
organization and within the society. The impact is beyond their control; hence they should
be seriously considered when decisions are made by managers. (Borawski, 1995)
For example:
(a) Bribes change governmental processes.
(b) Pollution affects environmental health.
(c) Unsafe products destroy lives.

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There is little disagreement here; most people recognized the extended consequences of
managerial actions. Disagreements, if any usually arise from the existence of multiple
alternatives, mixed outcomes, uncertain occurrences and personal implications that
complicate the decision-making process leading to those actions. (Brosnan & Roper,
1997)

In addition, such realities pose tremendous challenges to nursings integrity as a

profession. Without clinical ethics competence, nurses will not be viewed as participants
in clinical ethics discussions and will not be valued by patients, families, and other
healthcare professionals when discussing ethical questions. Thus, nurses can and should
become more knowledgeable about the interaction of ethical, legal, social, economic, and
political issues that affect institutional and public policy decisions. Nurses can seek to
address and influence these decisions individually and collectively. Expertise is a form of
power. A sense of powerlessness and moral distress in nursing often leads to inaction
rather than the leadership necessary to meet patient and societal needs for nursing and
healthcare. (Beauchamp & Childress, 1989).

2.2

Most Ethical Decisions Have Multiple Alternatives

It is commonly thought that ethical issues in management are primarily dichotomous, a

yes or a no choice, with no other alternatives.
For example:
(a)

Should a manager pay bribe or not?

(b)

Should a factory pollute the air or not?

(c)

Should a company manufacture unsafe products or not?

Although a dichotomous framework presents the ethical issues in sharp contrast, it does
not accurately reflect the managerial dilemma. Therefore multiple alternatives have to be
considered in making ethical choices. In this case, I have had multiple conversations with

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human resources, and looked at very aspect of each new graduate performance. It means
that I made my decision based on multiple alternatives. (Hiller, 1986)
Generally, ethics committees offer education, consultation, case review, and policy
development for the organization. Nurses contribute to institutional ethics committees
through discussions and deliberations either as a committee member or by appearing
before the committee as a patient advocate. Because nurses bring a strong clinical voice
and patient-focused approach to an ethics committee, they are essential members of the
committee. (Lutz, 1981)
Nurses may also consider establishing their own ethics committee. A nursing ethics
committee should not be a substitute for an institutional ethics committee. Nurses should
make an initial attempt to resolve a problem through the organizations normal channels.
However, nursing ethics committees provide a forum for nurses to share their concerns
and seek solutions when they experience ethical problems that are not being addressed by
the institutional ethics committees. (Roseneau & Roemer, 1996)
2.3

Most Ethical Decisions Have Mixed Outcomes

It is commonly thought that ethical issues in management are largely antithetical, with
directly opposed financial returns and social costs.
For example:
(a)

Pay an indirect bribe, but maintain the sales volume of imported goods
through prompt delivery.

(b)

Cause air or water pollution, but avoid the costs of installing and operating
pollution-control equipment.

(c)

Design a slightly unsafe product, but reduce the material and labor costs of
manufacture.

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Like the dichotomous framework, the antithetical model for outcome evaluation presents
ethical issues in sharp focus but it does not accurately portray the managerial dilemma.
Social benefits and costs as well as financial revenues and expenses are associated with
almost all of the alternatives in ethical choices. (Silva, 1990)
In this case, being a manager also entails an ethical obligation to support the goals of the
institutions and to comply with directives given by my administrative superiors even if it
will jeopardize somebody elses in starting a future career.

In the past, those who provided health care were presumed to be governed by beliefs in a
set of ethical and social responsibilities that took precedence over economic concerns.
Whether or not all providers have been guided by such ideals, providers, managers and
policy-makers alike must now take them into consideration along with the health needs of
recipients and the financial ramifications of treatment. (Van Amerongen, 1998)

Today, some executives and managers are accountable to profit-oriented boards,

depending upon the nature of the organization and its mission. State regulators must
exercise regulatory oversight on local institutions associated with sophisticated multiinstitutional arrangements. Some of these arrangements even span a variety of
communities in different states. In the face of changing institutional missions and
arrangements, third-party payers are likely to impose limits on expenditures based on
criteria that neither reflect nor embody the traditional (altruistic) values previously
associated with providing health care and professional service. (Lutz, 1981)

2.4

Most Ethical Decisions Have Uncertain Consequences

It is commonly thought that ethical issues in management are free of risk and doubt, with
a known outcome for each alternative.

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For example:
(a)

Pay the bribe, and receive the imported goods promptly.

(b)

Invest in pollution-control equipment, and emissions will be reduced.

(c)

Produce an absolutely safe product at an additional cost of Z dollars per unit.

A deterministic model that is, one without probabilities-simplifies the process of analysis
but it does not accurately describe the managerial dilemma. It not clear what
consequences would follow from the alternatives considered to avoid paying indirect
bribes to customs officials. Neither has it been clear what consequences will follow from
most ethical choices. (Lutz, 1981)

In view of this, after the graduates employment was discontinued, what is the probability
and consequences that she would face for the rest of her life. Probability in terms that if
she will be accepted again in this line of work and what consequences will take effect on
her self esteem and will to work. (Silva, 1990)

The ethical obligations of professionals who are health care executives and managers
may vary considerably from those who are providers. While the focus of providers is the
individual, the focus of policy-makers and managers is subordinated by obligations to the
organization, populations or entire health systems.

Decision-making dilemmas in our system abound. How do we reconcile protection of the

public's health and protection of individual rights when they are not mutually consistent?
How should scarce resources be allocated and used? How should we balance
expenditures and quality of life in cases of chronic and terminal illness? What are
appropriate limits on the use of expensive medical technology? What obligations do

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health care insurers and health care providers have to meet the "right to know" of patients
as consumers? (Roseneau & Roemer, 1996)

For managers, the ethical and equitable distribution of limited resources is no less critical
than the financial solvency of the organization. When maximizing retained earnings is an
expectation (such as in "for profit" organizations), fiduciary responsibility requires
managers to distribute resources in such a way that the needs and wants of individuals
may be pitted against those of the organization or plan and its shareholders. In countries
and localities that employ capitates financing of health services, a comparable fiduciary
responsibility and dilemma exists in representing and balancing public/government
interests and demands against the demands made by individuals on limited public funds.

2.5

Most Ethical Decisions Have Personal Implications

Most ethical decisions have personal implications. It is commonly thought that ethical
issues in management are largely impersonal, divorced from the lives and careers of the
managers. Many people believe that prima facie ethical decisions in a given operation
may reduce the profits of the company but not the executives salaries or their
opportunities for promotion. (Silva, 1990)
Managerial controls however are designed to record financial results of the operations,
not the ethical quality of the decisions that led to those results, and most incentive
systems are based upon these controls.
For example:
(a)

Maintain the dollar sales of imported goods at expected levels, and despite
slightly increased expenses for indirect bribes, the quarterly review will be
pleasant and remunerative.

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(b)

Delay the installation of pollution-control equipment, and the return on

invested capital will be close to the planned percentage.

An impersonal model certainly simplifies the process of decision on ethical issues, but it
does not accurately describe the managerial dilemma. Individual benefits and costs, as
well as financial and social benefits and costs, are associated with most of the alternatives
in ethical decisions. (Roseneau & Roemer, 1996)
The production and acquisition of resources (health personnel, facilities, drugs,
equipment, and knowledge) is not without consequences that force decisions about
resource allocation. From a public health point of view, the need for equitable access to
quality institutions and the fair distribution of health care facilities should take priority
over an individual real estate developer's goals or the preferences of for-profit hospital
owners.
Policy makers and managers may ensure the availability of a number of facilities that
create choices for communities. Whether the need is for public and private hospitals,
community clinics and health centers, inpatient and outpatient mental health facilities, or
long-term care facilities and hospices, the availability of facilities directly determines
whether choice is an option. In many urban centers, when there is a lack of choice, what
is at stake is the survival of facilities that provide an enormous volume of care for the
poor. (Silva, 1990)
3.0

Recommendation to Solve the Identified Ethical Problem

Utilitarianism, unlike deontology, emphasizes the consequences of act. Goodness is

basically defined as happiness or pleasure, and the right action is the one which produces
the greatest good and the least harm for the greatest of people. (Feldman, 1978,; Davis
and Aroskar, 1991). The consequentialist view does allow the breaking of rules if it can
be demonstrated that the greater good will result from doing so such as I the example

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above. It also provides a basic structural framework for conversations about health care
services.
Many current decisions of health care policy take as their moral starting point the notion
that finite resources should be distributed according to these principles. Thus we debate
whether enormously expensive transplant should be paid for with public funds when an
equivalent amount of money could immunize every child in the nation against infectious
disease.
Utilitarianism, like deontology, has serious limitations directing practical ethical
comportment. One of the more difficult problems in many moral dilemmas is discerning
what action really will produce the greatest good in the long run. It is not always easy to
arrive at a clear vision of the benefit or harm which would be created by a particular
decision. Utilitarianism does not help with this piece of this puzzle. Both traditions do,
however continue to shape our conversations within health care.
The participants in this study often experienced ethical dilemmas as a result of a conflict
between my obligations to support the business objective of my institutions and also to
support and care for staff and patients. This story provided an example of the impact of
changing economic environment of my workplace on participants every day lives. I often
find it difficult to balance my conflicting obligations, and I sometimes felt that I received
little support from administration from doing so.
This latter finding is important in light of previous studies conducted with nurse
executives who reported conflicts between their budgetary responsibilities and
maintaining standards of care as a frequent source of their own ethical dilemmas.
Although they seem to share the same concerns, this study suggests that upper
management can contribute to the difficulties such dilemmas create for unit-level
managers by failing to communicate with them about those concerns. The lack of
meaningful dialogue between participants and their supervisors about these conflicting
commitments caused managers to feel quite alone in dealing with dear problem.

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4.0

Summary

The ethical dilemmas of nurse administrators and nurse managers within the same
organizations might compare and contrasted. In addition to yielding information that
could help these two groups find common ground in which to address problems, these
studies could also examine the impact of institutional culture on the ethical dilemmas
experienced by participants. Since nurse managers have an important role in setting
standards on their nursing units, studying staffs perceptions of the values conveyed by
their nurse managers could yield important insights. Studies such as these might than be
used to make important connections between the ethical practices of nursing management
and patient outcomes.

REFERENCES

Armstrong, C.R., & Whitlock, R. (1998). The cost of care: Two troublesome cases in
health care ethics. The Physician Executive, 24(6), 32-35.
Beauchamp, T.L. & Childress, J.F. (1989). Principles of biomedical ethics (3rd ed.).
New York: Oxford University Press.
Borawski, D. (1995). Ethical dilemmas for nurse administrators. Journal of Nursing
Administration, 25 (7/8), 60-62.
Brosnan, J., & Roper, J. M. (1997). The reality of political ethical conflicts. Journal of
Nursing Administration, 27 (9), 42-46.
Fogel, L.A., & MacQuarrie, C. (1994). Benefits and operational concerns of health
clinics. Healthcare Financial Management, 11 (3), 40-46.
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Ho Jo Ann & Tee Keng Kok (2013). Professional Ethics. Meteor Doc. Sdn. Bhd.:
Selangor Darul Ehsan.
Hiller, M.D. (1986). Ethical decision-making in health management. Arlington, VA:
Association of University Programs in Health Management.
Lutz, H.S. (1981). Health maintenance organizations: Dimensions of performance. New
York: Wiley & Sons.
Mohr, W.K., & Mahon, M. M. (1996). Dirty hands: The underside of marketplace
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Roseneau, P.V., & Roemer, R. (1996). Ethical issues in public health and health
services. In R.M. Andersen, et al., Changing the U.S. health care system. San
Francisco: Jossey-Bass.
Silva, M.C. (1990). Ethical decision making in nursing administration. East Norwalk,
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Van Amerongen, D. (1998). A guide for approaching controversial, high tech procedures.
The Physician Executive, 24 (6), 26-30.

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