Can ethics be managed ?

In order to define and standardise the processes within and between the ethics committees, as well as those of the existing organisation of the care centres (see box), the management decided, together with quality management, to include these in the "core competencies" process. Subsequently, the individual processes within the ethics organisation were examined and their interfaces to other processes were elicited. Immediately after the interface clarification, it was defined which documentation was required. These included the following:

- – Checklist - Dealing with ethical issues: In this checklist, the entire process of dealing with ethical questions is listed chronologically. It is a complete description of all individual work steps (at the level of the process/ without ethical judgement) from the occurrence of the question to the implementation of a possible ethical guideline.

- Regulations - Case Reflection on Ethical Problems: This document regulates the path of ethical judgement formation and preferably serves the members of the ethics forum as a basis for structured case processing. After the detailed presentation of the situation by the applicant, all parties involved have the opportunity to ask supplementary questions. The Ethics Forum then examines in the first instance whether the case is indeed a moral problem. If not, the Ethics Forum makes recommendations on how to proceed. If there is an ethical problem, case reflection takes place using the three steps for ethical judgement formation according to Rippe (2012):

Step 1: Who has the final say? - here we check who ultimately has the decision-making power in the situation described. This can be the person being cared for, their relatives, an individual carer, the care team, the medical service, etc.

Step 2: Are the rights of others at stake? - Regardless of who has the final say, no rights of third parties may be disregarded. It must always be checked which other parties are involved and affected by the issue.

Step 3: Ethical balancing of interests - this third step only needs to be undertaken if two conditions are met: First, the final say must be with the care team.

Secondly, the measure under discussion must appear morally questionable at first glance - such as coercive measures or restrictions on liberty. This last step takes place in four further sub-steps:

1. is it really a suitable means?

2. is the measure indispensable?

3. weigh the advantages and disadvantages against each other

4. search to mitigate the disadvantages

After the decision-making process, the forum agrees on a joint recommendation. Consideration is also given to whether this is an individual case or whether the case discussed can be generalised to possibly produce an ethical guideline. The recommendation is formulated and documented in writing. In the case of a generalisable case, the text proposal for an ethical guideline is drawn up.

Participation of employees

Staff participation arises in many ways. On the one hand, all employees can participate in the ethics cafés. Due to the QM structure, it is possible for them to submit their ethical questions in a low-threshold way by means of the case vignettes. And employees from all areas of the company provide members for the ethics forum - membership is not only reserved for managers.

For the QMS, on the other hand, it is ensured that an ethics organisation does not create a parallel universe. Both the microstructure (e.g. the decision-making process) and the overall structure of the ethics organisation are implemented in a fixed structure. Ethical decisions flow directly into the overall system - i.e. also into the improvement cycle of the company. It is ensured that all employees have access to the "ethics" system. This prevents the creation of an elitist system that acts in isolation from the grass roots. Employees also have access to the decisions made. By documenting and communicating the decision-making process, transparency and traceability are ensured - which not least increases identification with the decisions and also represents an important factor for employee motivation and staff loyalty.

Ethical decisions flow directly into the overall system.

Standardized processes

All processes are standardized, which in turn corresponds to the specifications of a certified QMS. Nevertheless, the ethicists are given the necessary freedom that is needed for a fruitful discourse. Likewise, appropriate interfaces and other parties involved are taken into account and integrated into the process. The flow of communication and information is ensured. For this purpose, the QMS provides all necessary instruments in the form of documents, checklists and forms. And this without creating an excessive bureaucracy.

All ethical decisions are "archived" and must be regularly checked for validity. This prevents ethics from degenerating into an etiquette or a noble figurehead of the system.

Challenges

Organized ethics that exist only on paper and are not implemented in management processes in a verifiable and measurable way have no effect. Implementation requires both human resource development and organizational development - and the determination of management to initiate the process, to sustain it over time, and to work consistently on the resistance and obstacles. Organizations are generally very resourceful in resisting change processes. The introduction of an ethics organization is not exempt from this. However, a solid positioning of ethics in the strategic planning of a company is an important prerequisite to implement it in the organization (and thus also in the QMS) and to permeate the organization.

Such close interlinking as described in this practical example requires resources - apart from the fact that the maintenance of a QMS and an ethics organisation are already very resource-intensive undertakings in themselves. For those involved in QM, this interconnection means an additional amount of work. For example, with each new case vignette, the relevant documentation must be adapted by QM. In addition to the mere adaptation of the document, each mutation must be registered and historicized. It must also be ensured that the processes and communication channels are adhered to. Especially the communication and monitoring effort (quality assurance) was not insignificant during the introduction phase.

Despite the high effort, the described procedure seems worthwhile. The optimum can be drawn from both systems. Parallel universes were avoided - instead, a fruitful symbiosis of two systems took place.