Ethics and Trusteeship in Catholic Health Care
Goal of talk:
Boards know they have an ethical role; however, they are unsure of what to look
for, and how best to carry out that responsibility. This talk will provide an
overview of the issues and tools to use.
1) It is important to all of us that not-for-profits be governed well. Hospitals
deal with the most fundamental matters of human well being and their
services are not just another commodity in the marketplace.
 Even though trustees are volunteers (and they are strictly not a
profession) they are very much like a profession with roles and
responsibilities like any other profession.
 Reflection on the ethics of the role and responsibilities can be used
to facilitate, assist and enable already virtuous people to make hard
choices.
 As we will see the ethics of trustees is not about right answers but
about striving to do the right thing for the right reasons. The trustees
rightly ask what are the ethical elements that I need to be aware of?
 What tools in ethic can help me do my job better?
I will examine:
 What Trustees identify as “their ethical issues”
 Trustee’s role and how it creates unique ethical quandaries
 The responsibilities and what principles should guide them.
 The tools that are necessary to “navigate the ship”; how will you know
when you have fulfilled the ethical obligations of trusteeship
2) Why is this an issue now?
 Shifts in governance. With fewer religious and with a need to form lay
leaders to assume responsibilities for the “ministry of the church” there
needs to be a greater understanding of the moral tradition that informs the
mission. Traditionally people looked to the “professional religious” to
confirm the moral compass. .
 Changing responsibilities. In the past trustee’ primary concerns were the
selection of the CEO and philanthropy, but that is changing. Now trustees
are being asked to make critical decisions that relate to their institutions
core values, and sometimes it very existence. Several important
developments for governance structures especially cost containment
prospective payments have reduced reimbursement, short length of stay,
competition, bed supply have threatened the ability of hospital to pursue
mission-related activities. Also hospitals have become the site of many
complex moral choices including life, death, and healthcare decisionmaking.
1

Changing external environment: the Enron Tyco directors who seemed to
be asleep at the wheel. While cases like these unfortunately focus on
fraud and abuse as central issues in ethics (and they are not). These
scandals have prompted trustees to ask what more should they be looking
for? How can they better carry out their ethical oversight?
3) What is the ethics of trusteeship?
 Normally people conjure up images of scandal, abuse of power,
misconduct and the like, think of flagrant wrongdoing. This is not the place
to begin a productive conversation about hospital trustee ethics
 Ethics provides standards and rules for conduct; it interprets and clarifies
fundamental values, virtues, and principles that have proven themselves
over the centuries to be reasonable and beneficial to humankind.
 The study of trustee ethics has to do with the study of people who have
been placed in significant power and responsibility.
 Ethics in this case is the study of how such power is used, how human
beings should live together to mutual advantage, and the boundaries that
people should not transgress in their relationships with one another
 The most important part of trustee ethics is that trustee decisions are not
made alone but collectively. Trustee ethics requires not only attention to
those how they fill the roles but also the way the trustees act collectively.
 If trustee governance is to fill its high standards of ethical conduct, then it
is not enough to appeal to the ethical standards and consciences of
individuals.

A story about ethics trustees should start at the power and authority of
trustees. There needs to be some agreed upon standard because without
such a standard if the powers and authority of trustees is shifting,
ambiguous, and inconsistently applied, this is a recipe for irresponsible
conduct and lack of ethical accountability
4) Research indicates the common substantive ethical problems are:
o Institutional autonomy: Concern about maintaining a mission in the face of
fiscal pressures
o Financial issues: reducing costs is seen as the origin of many ethical
concerns
o Positioning of the hospital: how should the hospital respond to turbulence
in the health care environment
o Facility enhancement: enhancing quality, meeting unmet needs, and
finding the needed capital
o Physician relations: dealing with physician-related quality issues,
credentialing, and retaining physicians
o Managerial issues: strengthening and diversifying management teams and
the board
o Quality of services: concretely improving patient satisfaction and getting
board meaningfully involved with quality.
2
o Community role: how to bring together all the constituents to meet
community needs.
o Point: This qualitative information does not exhaust the list of substantive
issues that trustees thought were “ethical”; but they should be weather
bells/warnings that when an issues falls into areas there need to be a four
point ethics check. (which will be discussed shortly)
5) The role of the board causes ethics quandaries:
o The shifting responsibility from professional religious to lay people to carry
on the ministry of the church has left lay trustees in a quandary about their
obligation of “Catholic Identity”, how much formation they need. As
religious congregations form lay persons to take over ministry of the
Church there will be ambiguity of the roles.
o Trustee as representative: trustees are generally not elected by specific
constituents but as trustees are recruited to represent the diversity of the
community are they “representing them: or “speaking for”, should trustees
use their best personal judgment or make a decision that will be the most
acceptable in the community
o Trustees as mediators : unlike for-profit boards whose work is evaluated in
terms of enhancing stockholders investments; non-profits work is
ambiguous because they are evaluated in terms of meeting or mediating
the needs of several stakeholder—the patient, the community, physicians
o Assures community benefits: In smaller communities the meaning of
community benefit is relatively clear—board members can learn how
communities define their needs. However, in larger city it is difficult to
establish the communities since service area differed according to type of
service. Also when board members are not from the community and
governance by outsiders becomes the norm, then community benefit must
become an explicit conversation of the board
o Delegates responsibility; for example, do board committees become
problematical when it no longer serves responsible and competent
governance.
o Conflicting responsibility : what may be good for the community may be
costly to the institution
o Social versus economic values; board member often feel torn when
decisions are made for reasons other than economic.
Specific problems:
o Conflicts of interest: when a trustee might personally benefit from his or
her official actions and the benefits might bias judgments. Antidotes:
recusal, disclosure
o Board composition and deliberation: periodically the board should review
the hospital’s mission, composition of the board, operating procedures and
committee structure. Board deliberation
1. Do we have an open deliberative process?
2. Have we deliberated from a clear understanding of our mission?
3
3. Have we made explicit the principles on which are deliberations are
based?
4. When principles come into conflict, have we weighed the merits of
each?
5. Do we have a clear justification for balancing them in a particular
way?
6. Do we have an appropriate procedure for determining a
consensus?
o Shared or federate trusteeship
o Trustees on subsidiary boards
o Relation to administration and staff: trustees collectively should safeguard
internal policies and practices especially in three areas:
1. Quality of care: quality assurance, reduction of errors
2. Clinical decision making and patient care: patient’s rights
3. Human resource issues such as civil rights, discrimination
employee relations and benefits.
6) Major ethical principles of trusteeships
A sense of the ethical importance of trusteeship is suggested by the word trust
 Trustees have been entrusted with a mission and a set of assets. Those
assets have been created by years of charitable work by the religious
sponsors, private donation, public action (government / Hill-Burton) and
the trustees are responsible for seeing that they serve the public interest
in accord with the mission.
Trustees, like the professions are to adhere to a standard above and beyond
what is called for by ordinary morality in return for grants of power and
prerogatives.
o Fidelity to mission : fidelity means that trustees don’t perpetrate the past or
resist change, rather they interpret the mission in light of changing
circumstances and needs remaining true to the mission.(Mission = mission
statement)
o Trustees should use their authority and best efforts justly to promote the
mission of the not-for-profit and keep that mission alive by interpreting its
meaning over time in light of changing circumstances.
o Service to patients: requires diligent oversight of hospital performance
making sure that health is promoted in manifold ways, that policy and
practices are in place to protect patient’s rights and autonomy, and to
ensure that limited resources are efficiently utilized.
o Trustees should ensure that high quality health care is provided to patients
in an effective and ethical manner.
o Service to community ; not just sectarian interest (for example,
evangelization) but rather they are there to serve the common good—that
individuals can not flourish and be fulfilled without attending to the
structures that support it. Hospitals should deploy resources in ways that
enhance the health and quality of life.
4
o Trustees should govern hospital policy and deploy hospital resources in
ways that enhance health and the quality of life in the broader community
that the hospital serves.
o Institutional stewardship: they are concerned with interest greater than
financial stewardship—but all the moral community.
o Trustees should sustain and enhance the integrity of the hospital as an
institution, as an effective organization for the delivery of high quality
health care services, and a moral community of care giving.
If these are the roles and principle of responsibility then how do they get applied?
7) To engage these issues there needs to be consideration of the following
o Values based decision making process
o Screens that arise out of the Catholic tradition and mission and should
further assist in conducting an “adequate moral decision:
1. Social tradition
2. Ethical and Religious Directives
3. Mission and values
4. Strategic directions such as VIP
9) What informs trustee in VBD? Four point check
Social tradition
 Principles of Catholic Social Teaching
o Human Dignity: Everyone is worthy of respect
o Respect for Human Life: From “Conception to natural death”
o Association Person are not only sacred but social. People only
grow in association
o Participation
o Preferential protection of poor and vulnerable
o Solidarity
o Stewardship
o Subsidiarity: responsibility and limits on large bodies
o Human Equality
o Common Good: social conditions that allow people to reach their
full human potential
Ethical and Religious Directives
Mission and Values
Other programs
Conclusions
o Trustees have been given substantial authority and prerogatives and
therefore they have substantial role and responsibility.
o These roles and responsibilities are just beginning to be articulated and
are rarely discussed among boards.
5
o All of trustee’s decisions are ethical even though they do not avert to it
o They know they have made a “good decisions as long as values-based
approach has been used (the four point check), one that raises question
thought important screens that tell us who we are and where we are
going.
6