How healthy are your team’s business ethics?

October 7, 2012Carole No Comments »

I wrote this article for Journal of Clinical Embryology because I was concerned about the dangers of unregulated free enterprise driving the business of  IVF,  especially in  small stand-alone practices which operate under strong economic pressures without any independent ethical oversight. (Originally published in the Journal of Clinical Embryology, Vol. 15, no 3. Fall Issue 2012, pg 67. )

The medical ethics of Assisted Reproductive Technology (ART) is vigorously debated in both the public and private sphere but how to ethically conduct the business of ART does not usually receive the same attention. How business ethics are incorporated into day-to-day medical services depends in part on the type of organization from which ART services are provided. ART services are provided by independent businesses ranging from small stand-alone medical practices to IVF programs within large healthcare systems; in both environments medical and business ethics are equally important.

When attempting to nurture both medical and business ethics, large organizations may have an advantage because they have the infrastructure in place to address issues that arise in both the medical and business arena. The hospital-based ART team can take advantage of multiple departments within the system to ethically execute the business of IVF and can focus on providing quality medical services or research. When ethical issues arise in the practice arena, hospital-based ART employees can confer with the hospital ethics board for guidance. In addition, employees in a hospital typically have fewer day-to-day immediate concerns regarding generation of income as one department of many, compared to a stand-alone practice. In contrast, practice groups that independently provide ART services have almost no oversight or guidance to help them respond to business pressures.  In worst-case scenarios, ethics can become inconvenient distractions to the ever-pressing problem of making enough money to stay in business.

The challenge for the small business owner is how to succeed financially without compromising either their medical or business ethics. The current business climate appears to advocate that “greed is good”, “government regulation is bad”, and “only a chump follows the rules”. Market forces can’t ensure that ethics are a top priority and patients suffer when unregulated medical businesses turn a blind eye to inconvenient ethical imitations on their commerce.  Here are two hypothetical scenarios in which medical ethics are submerged to short-term business advantage.

Andrology Lab Scenario. The lab routinely performs a simple morphology analysis that includes “eyeballing” the sperm head but does not include performing actual sperm head measurements because the cost to upgrade the microscope to measure sperm length-to-width head ratios was not in the budget. These measured ratios are the primary criteria that differentiate the Kruger’s Strict Criteria from WHO criteria for morphology. However, the lab routinely charges its patients/insurance payors the higher fee for Kruger’s Strict analyses even though the essential sperm head measurements are not made. ICSI is performed on all IVF cases.

Embryology Lab Scenario. During freezing, a patient embryo is lost and cannot be recovered. Other embryos in the cohort are frozen for the patient without incident. To explain why all except one of the embryos were frozen, the medical chart includes a note that one embryo did not progress as required for freezing. The patient is also provided this explanation of non-progression for why not all embryos were frozen. When a team member questions the accuracy of the note, management dismisses the note as a “clerical” error.

Was the patient harmed in either of these cases?  Since ICSI was to be performed in all cases, was the actual medical treatment of the patient affected by performing morphology according to WHO rather than Strict criteria? On the other hand, what medical reason existed for performing a complex semen analysis with morphology, if only a minimal semen analysis could verify sufficient viable sperm for ICSI? Was insurance fraud committed in the Andrology lab by performing one test and charging for another? In the second scenario, the patient was correctly informed regarding the number of embryos that were cryopreserved. Was the patient actually harmed by changing the facts to preserve the image of the program? In both cases, it would appear that the business priorities (maximizing profit and protecting the brand) were the over-riding values of the organization.

ASRM’s ethics committee has published numerous policy statements regarding ethics in ART. ASRM steers clear of business ethics for the most part and focuses on medical ethics, but one recent publication by the ASRM Ethics Committee (Fertil Steril 2011; 96:1312–4) is applicable to the embryology lab scenario. “Disclosure of medical errors involving gametes and embryos” discusses when and how medical disclosure of errors should be made to patients. Although disclosure was generally recommended in most cases of medical errors involving the number or quality of gametes or embryos, there was disagreement among the committee members regarding when disclosure may be “discretionary”. According to one point of view, disclosure may not be necessary if errors “do not harm patients”. The other view argued that disclosure was always necessary under the principle of respect for patient autonomy.

The inherent weakness of using “harm to patient” as the litmus test of when disclosure is necessary is that “harm to patient” is often a matter of opinion.  Since the party that may risk harm from disclosure may be the ART provider, (e.g. in the form of a patient lawsuit), the ART provider may not be an unbiased judge of the patient’s best interests. In other words, be aware of confusing potential “harm” to patients with potential “harm” to the business. The true bottom line is that business ethics and medical ethics must be given equal weight and that principle is ignored at our peril.

Does your group discuss ethical scenarios or situations that arise that test your group’s values?  Do you feel that you can discuss ethical concerns you have within your team or with management? Perhaps one of the greatest predictors of whether you will be happy and successful in a work team is whether you have aligned yourself with people with similar ethics. If you are made uncomfortable by either the medical or business practices of your team, then your values are out of alignment with the team and you should probably start polishing your resume. You will be happier and healthier in a work environment that does not require you to compromise your values.

In a work environment that is characterized by unpredictable, overloaded work schedules, inflexible deadlines and emotionally stressed out customers, it might seem that there is little time in the day to ponder the medical and business ethics of IVF. But it is precisely that alignment of ethics that allow you to not merely survive but also flourish in the pressure-cooker environment of IVF as either an employee or business owner. A failure to tend to the ethical environment of your business may allow short-term successes.  However, long-term failure is assured as good employees burn out and leave or are continually churned out and replaced.

How can you go about tending to the ethical well-being of your team? One way is to make time to routinely discuss within the team the ethical issues that arise in the ART lab. At hire, the interview process should include questions about how the prospective candidate would handle medical and business ethical issues.

Team leaders have both the opportunity and responsibility to set the expectations of ethical conduct for the group. Why does it matter? Frequent contributor to Harvard’s Business Review, management expert Peter F. Drucker, explains that “Organizations, like people, have values. To be effective in an organization, a person’s values must be compatible with the organization’s values. They do not need to be the same, but they must be close enough to coexist. Otherwise, the person will not only be frustrated but also will not produce results”.  So aligning the ethical values of the group strengthens the team, and maximizes the effectiveness of each individual in that group. If you don’t have to constantly explain or defend the principle of “doing the right thing for the right reason” to your group or your boss, you can concentrate on serving patients to the best of your ability. And that might even help your financial bottom line.

Further reading:

Best of Harvard Business Review 1999 “Managing Oneself” by Peter Drucker Jan 2005 pp 19-29.

Ethics and the Business of Biomedicine. Cambridge University Press. 2009. Edited by Denis G. Arnold, Jule and Marguerite Surtman Distinguished Scholar in Business Ethics at Belk College of Business, University of North Carolina, Charlotte.

© 2012, Carole. All rights reserved.

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