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In the context of all of the discussion about "Fletcherian" ethics consultation, we're including this description of ethics consultation for clarity and in deference to the work of John C. Fletcher. It's reprinted from the third edition of Fletcher's Introduction to Clinical Ethics.

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The recognition that the success of the healthcare organization depends on its achievement of two interrelated goals is a relatively recent phenomenon. In its mid-history the healthcare organization was largely able to ignore cost issues. In its latter history, many would argue that it ignored its quality goals as it pursued its cost goals (15). Either approach, given declining revenues and a competitive landscape, is incompatible with continued responsible operation. If this is true, then tools that were appropriate when the healthcare organization was focused on the achievement of one or another of these goals are not adequate as the healthcare organization seeks to achieve both goals together. Thus, new perspectives and new tools must be found that help the organization address two intimately related but sometimes conflicting goals. Values based decision-making can be the perspective needed, and organization ethics is one tool that can be of use in supporting it within the institution. But there are caveats. In order for values based decision-making to be effective, leadership must take an active role in promoting its use. It must relinquish a degree of control and it must begin to trust its stakeholders to make decisions within the context of the organization's values and goals. This can be extremely difficult, as control by senior management is often seen as the only effective means of ensuring that correct decisions are made. There are additional difficulties in the healthcare organization. Control rests within two groups and the healthcare organization is operating in an environment in which variance elimination is emphasized as a means of controlling costs. This may be an appealing notion for revenue strapped healthcare organization leaders, but it implies greater control exerted by managers, not less. Relinquishing any degree of control is a frightening prospect, but it has been done successfully. An excellent example of leadership encouraging decisions based on values was presented by a unit administrator frustrated by the hierarchical structure and ponderous rituals of a traditional intensive care unit. Invoking a management tool called "the balanced scorecard" (which recognizes the multiplicity of goals and values in any organization) he identified the goals and values of the unit, and with the help and input of his staff he restructured it into functional multidisciplinary "teams" organized around tasks and goals which were based on values. The transformation of identities of unit members from their job description to their accomplishments improved both the efficiency of the unit and its morale--as well as resulting in cost savings. In this example teams had to learn to work together, collaborate and disregard the fear of doing things differently. Staff had to be motivated and feedback was necessary to ensure goals rather then rules were being meet. The balanced scorecard was implemented with mechanisms to support the communication and collaboration necessary to achieve the goals of the unit. The experiment was successful, but only because leadership recognized that multiple goals and multiple values were involved, that were explicitly articulated with the priority of excellent care. But once leadership was sure that "shared vision" existed leadership was able to trust staff to make appropriate decisions to realize that vision.

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Evidence-based medicine purports to be the integration of three prongs; best research evidence, clinical expertise, and patient values and preferences. Controversy still surrounds the application of evidence-based medicine and undoubtedly controversy will persist in the treatment of specific diseases, thus allowing for some flexibility in decision-making. Yet, the idea that variation is expensive has gained wide acceptance and variation can best be controlled through rigid systems. So given the financial constraints facing healthcare organizations, as well as pressure from such august organizations like the Institute of Medicine to implement evidence-based medicine, flexibility in decision-making may ultimately become the exception rather than the rule. Certainly, in the short-term, the advantages of a rigid system, notably its cost advantage, overwhelm the advantages of a more naturally adaptive system--and so where possible evidence-based medicine will probably be implemented within a rigid context. Rigidity in system design will affect the activities of clinical ethics. To be effective in such a system, clinical ethicists will need an understanding of the system within which they practice including its values, goals, operations, and tools. This is a knowledge area which few in this field currently have and which they may not wish to acquire. But, if clinical ethicists expect to have credibility in responding to these changes, they must understand the values, goals, processes and outcomes of the system in place and be able to advocate for greater flexibility and greater attention to patient values and preferences even within a rigid mechanical system.

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The Virginia Bioethics Network (VBN), a self-governing, self-supporting organization of Virginia healthcare institutions and other interested groups and individuals, was officially incorporated in the state of Virginia in December 1993.... The mission of the VBN is to advance the knowledge of biomedical ethics within Virginia healthcare institutions and their communities and to support the development of local institutional ethics programs and regional ethics networks throughout the state. The ultimate goal is enhancement of ethical decision making in the clinical setting with all pertinent factors, including community values, being given due consideration during the decision-making process....

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