Business Aspects of Health Care
and Woodstock Methodology

By James L. Connor, S.J.

The Woodstock Theological Center has developed a unique approach to contemporary issues based on the theological method of Bernard Lonergan, S.J., and the spirituality of St. Ignatius Loyola. Here James L. Connor, director of the Woodstock Theological Center, explains how the Woodstock methodology was used in the Business Ethics Seminar in developing the consenus statement on Ethical Considerations in the Business Aspects of Health Care.

The aim of this seminar was to produce a brief and practical consensus statement of the participants which would help busy health care providers make daily decisions in the business aspects of their profession that are ethical. They reached agreement on a checklist of questions that practitioners need to ask themselves in order to be sure their decisions are ethical. They reached agreement, in roughly 95% of the cases, on what the better course of action would be in particular situations. They left some few cases undecided, but stressed what goods or values would need to be safeguarded in any decision if it were to be ethical and moral. They offered this advice and these recommendations only after having described the "landscape" of the health care world at this point in history-how it has changed and what new challenges it presents.

So, the goal was a very practical one (as was also the case in our two earlier Woodstock business ethics seminars: Ethical Considerations in Corporate Takeovers and Creating and Maintaining an Ethical Corporate Climate). The publication, therefore, is, by express intent, a "how-to" manual, not a philosophical tome.

The 40 or so participants were chosen because of their preeminence in the field, their wealth of experience, and their reputation for probity and integrity. They were chosen also with an eye to variety of experience: physicians, nurses, hospital administrators, insurance carriers, ethicists, policy specialists, heads of national medical associations, business executives, and so on. All of us have been patients at one time or another. They came from all over the United States. Some were in private practice, some were in public health service, and some taught in medical schools. Among the physicians, there were different specialties represented ranging from internal medicine to psychiatry. Some physicians were also ethicists by training.

The seminar took two years to complete. There were four day-long meetings of all the participants. The seminar was guided by an eight-person steering committee which met at least once between each of the day-long meetings to assess the previous meeting and to recommend the objectives and format of the next meeting, as well as to evaluate the progress of the whole project to that point. An executive committee of four people prepared the materials both for the steering committee meetings and the seminar sessions: the coordinator of the project (Jim Connor), the executive assistant to the project (Adoreen McCormick), the rapporteur of the project (Margaret Blair), and an in-house ethicist (John Langan).

Each session was thoroughly recorded by a court stenographer, and delivered to Woodstock ten days after each meeting. The executive committee then went to work on the transcript to analyze it, understand what the group was really saying, to develop some recommendations for the steering committee about how to proceed in the next meeting, and to decide what materials (summary reports, models, recommended format, other readings, etc.) would need to be prepared and mailed out in advance to the seminar participants.

We were gradually working toward a consensus statement, but there were a series of discrete steps that we needed to go through in order to reach that goal. The following are the major steps along the way:

(1) Story-telling: getting out the data

The first step, and the objective of the first full-day seminar session, was sharing anecdotes and telling stories of actual experiences of ethical conflict with which the participants found themselves confronted on a fairly regular basis. We didn't want to discuss these stories-beyond just getting clear about the facts of the matter-nor did we want to "solve" the moral dilemma. The aim was simply to get the data on the table. What are the moral and ethical questions that arise out of the actual experience of the practitioners? We did not want to go to textbooks to find cases; we wanted the feel and the smell, the overtones and the undertones, etc. We did not want to monitor or classify the stories, choosing which ones were more important or vital than others. We didn't want participants challenging one another (e.g., "That's not an ethical dilemma!"). We wanted to know what each of them thought a concrete instance of an ethical dilemma was.

It is not easy to keep a group like this simply telling stories. The tendency of many is to want to leap immediately to their theory of what ethics is and what course of action would be ethical in this or that situation. But you need to surface the broadest possible database of actual experience at the earliest phase of this two-year long process. Otherwise, some really important dimensions of health care might be totally overlooked. Or you'll find in a year's time that you have to double back and re-begin the process of data gathering. And that would be very disruptive. Moreover, the group members need to hear one another, to learn the varieties of experience that are represented around the table, and to come know one another in more than a superficial way. The stories are often deeply touching and highly emotional, and so is the story teller when he or she tells it. This already tells you a lot about each of the participants. In the sharing, the data becomes shared data, and there is a "community pool" of experience which engages, and, to some extent, bonds the participants as a group.

In brief, then, the first step is to get the DATA up and out, onto the table. And to get it from the primary source: the practitioners themselves who are "living" the data.

Lonergan: The first step in Lonergan's method is "Be attentive!" By that he means pay attention, notice the data, see what is under your nose, don't overlook anything vital. The data arises from our experience either of sense (see, hear, smell, taste, and touch) or inner consciousness (ourselves thinking, feeling, questioning, etc.). Things always and invariably come to our attention, but we need to advert to them and also to the questions that the data arouse in us. Slothful, sloppy, selfish, and otherwise preoccupied people can go through a lifetime and simply not pay attention to extraordinarily important data.

Ignatius: Like Lonergan Ignatius always insists that we start and stay close to our actual experience. He eschews "head trips." He wants us to be able to say what's happening-both in the realms of our experience (treating patients in this case) and in ourselves (what are we feeling, thinking, questioning, wondering, etc.)? All of this becomes the basic data for understanding, reflection, and choices of promising courses of action. But miss the data, and everything else goes awry.

(2) Understanding: what's really going on?

After the first meeting the executive team read the transcript and recorded all the stories as faithfully as possible. These stories were mailed out to all the participants so that they could remember them and also begin to think about them and what they meant. The executive committee also tries to organize these disparate and apparently unrelated stories into some kind of a pattern-hopefully without doing violence to the meaning and intent of each of the stories individually. Questions the executive committee asked are: are there a few "major headings" under which various stories might be grouped (for instance, "conflict of interest" or "confidentiality")? Are there some common threads that run through some or many of the stories? Does a pattern, like the new management system of health care (that is, the shift from fee-for-service to third-party payer), seem to explain many of the conflicts that arise? And so on.

After a consultation with and approval of the steering committee, the executive committee mailed to the participants: the stories told at the previous meeting, an analysis and recommended organization of the stories, the objective of the next day-long session, and a suggested format for the day.

The objective of the day-long meeting was for the whole group to do what the steering committee modeled for them: make its own analysis of these stories and decide on how they might be organized. "What do these data mean? How do we explain these dilemmas? Are there any root causes which we need to identify and understand?"

We understand something precisely when we get an insight into the way bits and pieces of data fit together in a pattern which relates the pieces to another. Think of Sherlock Holmes. He sees a hank of hair, a rusty nail, a bloody sock, and footprints in the snow. And after pondering, he screams "Eureka, Watson. It was the butler who did it!" And then he explains how all the pieces "fit": the sock is the butler's, the hank of hair in his pocket is the victim's, the footprints in the snow are size 14 AAA (which only the butler wears), and only the butler had the key to the carpenter shop where the murder weapon, the rusty nail, was kept. Physicians do the same thing when they diagnose your illness: they gather all the symptoms and see how they "fit" together to explain what's wrong.

It is interesting how different people will organize data differently, and have, therefore, quite different understandings or interpretations of what is going on. In large measure it has to do with their different perspectives or points of view. At the health care seminar we had doctors who were very uncomfortable hearing "business" applied to care of patients. For them, "business" was equivalent to "(a crooked) used care salesman," while medicine is a profession pure and simple. Their primary, almost sole, responsibility was to their patient's health, and how to best to assure it. Let someone else worry about finances, systems of payment, facilities, and the like. Hospital administrators, for their part, were extremely concerned about cost, and (secretly) called doctors "prima donnas." Administrators were concerned with patients, but they also saw that patients would suffer if financial resources became scarce. In their own way, nurses were more patient oriented and concerned than were many doctors. Doctors, nurses said, breeze in and breeze out, while they have responsibility for the day-in and night-out care of people. And when records were falsified by doctors for the sake of getting money from insurance companies (like not recording the patient's condition of AIDS), then the nurse stood to be infected unwittingly. Insurance carriers, of course, had their own point of view and were very sensitive to the doctor's charge that they were bilking patients and the whole health care system by scrimping on the procedures they would approve (like only one overnight for childbirth). For their part, they resented doctors who had become millionaires by bilking insurance carriers in "the old days" of fee-for-service.

"Health care" to all these people meant different things, according to their perspective. The perspective was formed by their role and their experience in that role. It was also formed by who or what they valued, in what priority ranking. Their own identity is tied up in this perspective. "What is a doctor" to some evoked the old time family doctor braving the blasts of a dark winter night, little black bag in hand, to reach the bedside of a woman about to deliver at home, thoughtless of remuneration. That is the ideal of "doctor," to which all should strive. That's, at heart, what "doctor" means. To another it means well-financed research opportunities and excellent clinical equipment. Let the midwife care for the birthing mother; the doctor should be on the cutting edge of new techniques for the future good of thousands of expectant mothers! For yet others, the really important dimension of health care is an overhaul of the entire system of delivery. Very soon no one will reach the financially poor mother-to-be on a bleak winter night, unless we re-think and reorganize the entire system.

Each of these perspectives had some truth to it, but each was partial and insufficient for understanding health care. Alone they were like the blind feeling the elephant and pronouncing that it was tail, a trunk, a foot, or whatever. And it wasn't enough they share their perspectives and understandings of health care in order to make the whole out of the sum of the parts. In order to reach a consensus, they each had to stretch to get an appreciation for the viewpoints of others and thereby to have their own perspective changed, so that they, each and all together, could acquire a new, broader, holistic and therefore accurate view of health care. Otherwise they could have reached consensus on very, very little and done so only on a very superficial level, because their disagreements would have continued to be many and deep.

In the course of the seminar sessions, the participants underwent real "conversions" of viewpoint and perspective. A doctor who had been very dismissive of business and finance had to listen to a CEO of a major corporation talking about the basic requirements for any institution to behave ethically-only to realize that business people have paid much more attention to the ethics of the business and finance than almost any health care providers have. And in some ways business is way out ahead of medicine in institutional ethical sensitivity. For their part, physicians really challenged "policy wonks," telling them how clear it was that they had never been part of the tragic, personal dimensions of severe illness, and that, therefore, when they modeled health care financing schemes, they were living only in their own heads. And so on for all the different participants and their respective roles.

Besides the difference that role plays in perspective, there is also the difference in basic human values that each person cherishes. We had a wonderful group of people and there was no one who was greedy, selfish, insufferably vain, or the like. But it was clear occasionally that some people were much more compassionate and willing to self-sacrifice than others; some were instinctively protecting their own turf or minor idols; some were narrow minded in their personal philosophy and couldn't stretch to reach a higher ground on which they could have integrated other philosophies; and so on.

I mention this simply to show that a perspective is a deeply personal thing, and it has moral, and even religious, not simply intellectual dimensions. We are responsible for our viewpoints, and when it has been significantly influenced by pride or stubbornness, then it is the product of moral flaw as well as intellectual inaccuracy. It takes good people to be consistently right! Wisdom is much more than IQ! The truth shall set you free, perhaps because it takes a humble person to reach the truth.

(3) Passing judgment: "Health care is ....

Having made the effort to understand (organize the data into an explanatory pattern) by exchanging experience and growing, through "conversions," to a substantially shared perspective, members of the group were ready to make a judgment about the truth of the explanatory pattern or patterns that they came to recognize. So, they said, "This is so!" Pages 1 to 8 of the publication, Ethical Considerations in the Business Aspects of Health Care," are a statement of what the group understood health care to be.

For a group to come to judgment, and know that it has reached a judgment, is very important. It is like laying the foundation on which the rest of the house will be built. Without a clear "moment" of agreement on "what is" you will be in constant frustration when you try to reach agreement on what "what should be done?" or "what is ethically or morally correct," because the sands will be shifting and sliding underneath you.

(4) Discerning, deciding, doing

Over the next two meetings, the group worked toward its recommendations about the ethical course of action to take in particular cases or areas of conflict.

a. Discerning

They started by breaking into small groups and looking at the stories, now organized according to their understanding and judgment about health care today, and choosing the moral "maxims," or "rules of thumb," or principles that might be applicable in particular cases. Sometimes, several maxims were found to be helpful in the same case, either complementing each other or apparently contradicting one another. The "baseline" criterion for choosing one maxim over another is the value that participants set on one "good" over another. For instance, some people thought patient confidentiality ranked much higher as a good than full disclosure to the insurance company (and possibly, therefore, to the patient's family). A participant's preferential "pecking order" of goods depended, in turn, on how he or she understood health care and the responsibilities inherent in it.

This exercise of maxim choosing, therefore, led participants to recognize how and why they had different rank orders of goods and values, and to work to reach agreement on what truly are the more important goods. They listed and described these goods in terms of the complementary virtues or values that health care providers need to cultivate in themselves if they are consistently, regularly, and accurately to make sound ethical decisions in the various dimensions of health care.

b. Deciding

The list of responsibilities, virtues, and values was hammered out over two intensive meetings and appears on pages 9 to 14 in the consensus statement. It opens with what, in the group's estimate, is the most essential characteristic or responsibility of a health care provider: "The first and foremost responsibility of ... health care professionals is to attend to the health needs of the individuals in the communities they serve." Then it speaks of three other goods for which health care professional are responsible: the resources for providing health care, the advance of education and technology in health care, and the education of the public as to its own health care responsibilities.

The first responsibility quoted above has a heated history. Some participants wanted to say simply that the physician is responsible primarily, if not exclusively, for the health care of his or her patient. Others felt that such a statement would be short-sighted and socially insensitive. The physician, they maintained, has to feel responsible for all his or her patients, and even the pool of patients, actual or potential, in the community the physician is called to serve. In fact, some in the group wanted that social responsibility to get top ranking over the physician-patient relationship. But most physicians were adamantly against that. These goods. and the values they embody, were imbedded, as we saw above, in the perspective, viewpoint, or "horizon" of each participant. And each needed to "stretch" through dialogue with the others in order to reach a consensus.

A note in passing: Without consensus a publication like this could not have been written. But more important than that, without a real consensus in society at large on certain key questions, society cannot operate either at all or very well. It is plagued by obstructive division, and everyone suffers, because, without agreement, we cannot work together for the common good. This is the deeper value of the kind of exercise we were pursuing in the ethics seminar on health care.

c. Doing

Having agreed on how we need to understand health care today and having decided on the framework of values that need to be operative in any sound ethical decision, the participants went on to develop recommendations for courses of action to be taken in concrete cases (stories) which they had surfaced at the very start of the process. For instance, is it ethical for a physicians to own, in whole or part, a health care facility, like an MRI, to which he or she refers patients? Or is that a morally unacceptable conflict of interest? When two severely injured patients are simultaneously rushed to an emergency room should their financial means be of any consideration at all in choosing who to treat first? Is a physician ethically and morally always obliged to make full disclosure of a patient's condition on insurance forms, or do other goods sometimes take precedence over the good implied in utterly accurate information?

If you read the publication carefully, you will be able to sense, I think, the blood, sweat, and tears (almost) that went into the gradual formulation of these recommendations. But the group did make decisions, which they wrote down on these pages, and signed on to for all the world to see. That is an action, and it is of no small import. Ethics is not simply thinking about, or weighing and deliberating, or planning to do such and so, but it is in doing the good thing.

Therefore, if the aim of this exercise in business ethics were not to push participants finally to act by signing on to the consensus statement, it would be a totally different-and far less valuable-experience for both the participants and for the public they were seeking to help. Without the drive or pressure of this action, people could have talked, talked, talked endlessly and comfortably, as is too often the case in academia. It was in "going public" (acting on) their decisions that made the exercise real and serious, and therefore helpful.

Since the action was a consensus recommendation it also forced or pressured people to come together and understand one another, argue with one another, be sympathetic to different viewpoints, and to plumb deeply enough to uncover common ground for a consensus. They simply would not have taken the energy, the time, the personal and motivational self-scrutiny, and the exhausting thought to do all this if a public consensus recommendation were not the action-goal before them.

Finally, it is in the taking action that they were exercising responsibility not only for the health care field but for their own growth and development as individuals and, together, as a group. Moral maturity consists in consciously accepting the burden and the privilege of creating not only our world but ourselves, as well.

The publication concludes with a "Checklist" of questions which a practitioner can put to himself or herself when facing an ethical decision in the various areas of conflict that were considered in the course of the seminar. The questions call the attention of practitioners to data they might otherwise overlook, situations they might misconstrue, values they have failed to appreciate, conflicts they may not have suspected, and so on.

These questions are ones that the whole seminar group had to face for themselves, and therefore the group "models" the way such questions have to be dealt with. If you look over the questions, you will find that they invite the practitioners to do for themselves the steps which the seminar group went through: pay attention to the data, try to understand it, make a judgment and say clearly what indeed is the case or situation, and then move on to discern, decide, and do what you feel and believe is the ethical course of action.

Raising questions is at the very heart of the Ignatius - Lonergan methodology. It is conventional wisdom that if you don't ask the right question, you won't get the right answer. It is also important to know what kind of a question you are asking. Is it a question for data? or understanding? or deliberation? or decision? Different kinds of questions expect different kinds of answers, but we can get confused about the answer a particular person expects, and thereby go astray. For instance, more data is not necessarily going to help a physician enlarge his or her perspective. He or she may simply "fit" the new data into their traditional "model" of what health care is. A persuasive appeal to their feelings of compassion, care, and concern may be what is needed, by raising questions of goods and value.

Perspective

A concluding remark on perspective. We have seen above how professional role and personal experience help shape one's perspective or point of view. Our perspective can also be called one's "horizon": the context within which the data gets located and situated. Within the horizon some things are near (important) or far (less important). Big or small. Some things are simply beyond our horizon, and for all intents and purpose simply do not exist for us. We can't see them.

This horizon is constituted by what we are interested in and what or who we care about, what is meaningful and valuable to us. The chemist sees things and values things that the carpenter doesn't, and vice versa. There are levels of horizon-some rather superficial and narrow in gauge, and others very broad and profound. All of us live with many levels of horizon related to things like profession, ethnic origin, neighborhood, and religion.

Religious belief is the broadest, most profound, and deepest level of horizon. The person of Christian belief is interested in and cares about Jesus. "He loved me and gave up his life for me," St. Paul exclaims. And goes on to say, "I lie, now not I alone, but he lives in me." "For me to live is Christ, and death is gain." As the revelation-in-action of God's unendingly steadfast and all- comprehensive love for us, Christ sets the horizon within which our life has meaning, value, significance, joy, and purpose for us.

We refresh and re-live this horizon by re-telling the stories of his love and mercy. That is what we do as a community every time we participate in the Eucharistic Liturgy. We do so by re-telling the stories out of the Gospel and the rest of the New Testament. In telling that story, we recognize the basic elements of our story in the world here and now, today and into tomorrow. Jesus and the Good News he brought and is for us is the key criteria for the data we select as important, the interpretation or understanding of the data we judge to be accurate,. and the good(s) that we discern to be pursued in action. The Christian perspective is, we believe, as deep, and broad, and profound, as is humanly possible in this world-and is accurate, as well, because it is reflective of the true God. "Who can separate us from the love of Christ Jesus our Lord. Death, breadth, etc." It is an abiding experience of being loved, and thereby enabled to be loving.

The important thing here is to see how our faith-horizon is related to and operative in all the mundane deeds we do each day: seeing, hearing, smelling; questioning, inquiring, seeking to understand and interpret; reaching a judgment, "it is this!;" and moving on to ask, "What's to be done about it?", through discerning, deliberating, and deciding.

We did not elicit religious belief in the health care seminar. I know we had Christians, Protestants, and Jews. I suspect we had some non-believers. We did, therefore, explicate, this level of horizon. But we definitely had people of great good will. So our horizon was broad enough, thick enough, and deep enough, to come up with a remarkably helpful ethical consensus. In society at large, this is our constant challenge, because we can presume great religious diversity.

A final note: The chairperson of these sessions has to understand the "why and wherefore" behind the steps through which the group is moving and what activities each session will require in order to achieve its basic purposes. Besides this theoretical understanding, the chair must also be skilled at actually facilitating the conversation, the reports from break-out groups, and other processes or exercises that are used.

But group members don't need to know the theory or the explanation I have offered above. Most active people don't have the time, the interest, or the training to understand why it is we behave as we do. But as much as they can absorb, the better for them. If we know what knowing and loving consist of, chances are good that we will do them much better than otherwise. We become our own walking "Checklist!"

James L. Connor, S.J.
March 18, 1996

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