Collective Values and Roles in Management
So far, I have discussed collective responsibility in health care in terms of the shared attitudes and values of doctors, which to a great extent and in various ways determine their actions and affect their moral responsibilities.
But a very different kind of collective responsibility is also present in health care, because a great deal of health care takes place in hospitals or other large group practices. Hospitals are corporate persons, that have aims, values, and responsibilities that differ from medical ones. Two questions arise here: how does the existence of corporate persons, such as hospitals, affect my conceptual/philosophical claim that only human individuals are morally responsible; and how do the values of corporate persons such as hospitals causally affect the individual decisions, and therefore responsibility, of its employees such as doctors?In answering the first question, I stress that the essential attribute of corporate personality is that, upon incorporation, the company becomes a legal person distinct from its members, such as its shareholders. The corporate person can then sue and be sued in its own name; does not cease to exist if its members die; and can have debts for which its members are not liable. Corporate personality is therefore a useful legal concept, but crucially, it is an abstract concept: it separates its responsibility from that of any group of individuals who happen to be members of the corporate person at any given time. Of course, the individual persons who are employed by the corporate person carry moral responsibility for their roles in the business of the corporate person, but (to answer my first question) the corporate person itself carries only legal responsibility and not moral responsibility.
A corporate person is a kind of collective familiar in politics and business: it has a clear structure, hierarchy, and decision procedure.
An example of a structure of this kind is the Cabinet within the UK government. Its members are individually morally responsible for their own views and advice, but the Cabinet acts as a unitary body over important matters. It therefore carries the corporate responsibility of a legal person (French 1979: 297—317). Large businesses have a similar structure, and in the same way, are corporate persons that can be held responsible for their actions. But the responsibility in such cases is legal, rather than moral. Large hospitals or hospital trusts are in this category: they have boards of management and chief executives; maintain tight control of decision-making; and, if they run into financial difficulties, may be fined by governments. But note it is the corporate person, the trust, which is fined, but not the individual managers (although they may be sacked by the board of management). It is true as an empirical point that we do sometimes pass moral judgments on the corporate person as a whole, including hospitals, without especially thinking of the individuals who work in them. But this is a convenient fiction that allows the public to express their feelings through moral judgments.My second question concerns the ways in which the attitudes and values of corporate persons, such as business or “the market,” are liable to have a causal influence on the decisions of the medical staff that work within hospitals regarded as corporate persons. The values of business or “the market” were first stated by Adam Smith in 1776, and they have not been modified very much since that time. In a well-known passage in The Wealth of Nations, Smith tells us that it is not from the benevolence of the butcher, the baker, or the brewer that we expect our dinner, but from their regard to their self-interest (Smith 2008: 22). This passage is the classic statement of the view, taken as a given to the present day, that self-interest underlies all market transactions. Smith later expands this view by including competition and profits as essential to market transactions.
These are the values of market or business transactions; hospital trusts as corporate businesses will therefore be organized and administrated with those same values and aims. In terms of the concepts I have so far used, the role of manager or chief executive will be constituted by the values of institutional self-interest, the need to succeed in competition and to make profits. Just as the collective values of medicine permeate medical education, so business schools cultivate the values and attitudes of the free market. Moreover, the role enactment will also have been strongly influenced by management training: even if the chief executive was originally a doctor, the subsequent management training will have greatly modified the original medical values. It is therefore inevitable that the differences between the collective values of medicine and those of management are likely to lead to conflict. For example, in the UK, the need to meet government targets or satisfy shareholders may result in a decline in patient care; the emphasis will be on quantity of through-put rather than quality of care, which is likely to lead to poor morale among the medical staff. The collision between two sets of strongly held collective values does not make for coherent policies in health care, and it can create dilemmas of moral responsibility for the medical staff.
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