Legal & EthicsPractice MattersWorkplace Management

For once, ethics and the ‘bottom line’ agree


In a rare moment of cooperation, the American Hospital Association, the American Medical Association, and the American Nurses Association released a new report that found up to 766,000 healthcare and related jobs could be lost by 2021 as a result of the 2% sequester of Medicare spending mandated by the Budget Control Act of 2011. As there will be no reduction in healthcare benefits, but most likely an increase in demand for services, all the cuts will be in payments to providers with a trickle-down effect on suppliers. Even on a direct employment basis (that is, only counting those jobs directly paid by the recipients of the funding dollars, such as nurses, other caregivers, housekeepers, independent contractors, or residents receiving training), the funding cuts will be responsible for a substantial loss of employment nationally. During 2013, the direct negative employment impact is estimated to be 211,756 jobs; by 2021, this direct negative employment impact is estimated to be 330,127 jobs. So what does this mean to hospitals and other providers? Undoubtedly more emphasis on the bottom line.

One of my favorite books is Laura Nash’s Good Intentions Aside: A Manager’s Guide to Resolving Ethical Problems (Boston: Harvard University Press; 1990). In thumbing through the book, I came upon a subsection entitled “The ethical implications of a bottom-line orientation.” Mind you, this woman has not, insofar as I know, worked, consulted, or even written for healthcare executives. No, indeed! Her work is directed toward the business executive. And what does she have to say about a bottom-line orientation? “…when profit becomes the dominant purpose it is not just prioritized, it is ‘exclusified.’ Profit is so concrete and ‘strong’ a claim, and ethics so abstract and process-oriented that the former [profit] easily gains dominance over the latter [ethics] in decision-making” (p. 134). Do tell!

“….This bottom-line pre-occupation not only emphasizes the achievement of economic success to the suppression of other important goals, it also undermines the moral norms regulating the means to success….Moral obligations such as honesty or reliability are excised for the sake of success….The moral fallout from such rationalization can be as small as tampering with the taste of a brand name, or as deadly as the failure to correct defects in a brake design” (p. 137).

Bottom-line thinking in health care

While bottom-line thinking in business clearly has many serious implications, bottom-line thinking in healthcare organizations can honestly be described as lethal. The problem, as Nash so eloquently explains, is to develop ways of recognizing when the pull of the bottom line is overtaking both common sense and common decency—and, of course, doing something about it. Nash suggests:

1. Look for moral paralysis: Bottom-line thinking is the most common excuse for doing nothing, seeing nothing, and saying nothing when dangerous decisions are being made.

2. Set forth a framework of questions to ask yourself—and discuss openly with others; otherwise, bottom-line thinking may blind us to a self-serving framework of analysis. To break that cycle, make it a policy to ask:

a. Who might get hurt (besides us) if we choose this particular course of action?

b. How is the problem being defined? When the discussion is framed in terms of the organization’s needs to the exclusion of the needs of patients and personnel, bottom-line thinking has taken over again. Reframe the discussion in terms of all three stakeholders—patients, personnel, and institution.

c. What language are we (or am I?) using to set goals for other people? When you choose bottom-line language, you promote bottom-line behavior (profit-at-any cost, cut-corners, the-company-comes first) that communicates to employees what you think is important and what you will reward.

d. If the decision(s) were to be published in the local newspaper, how would it (they) affect the reputation of our facility? Any time decisions are made on the premise that the public is not going to know about them (find out?), you are in ethical hot water.

3. When in doubt, ask the ethics committee.

For some years now, hospitals have had ethics committees whose purpose is to discuss clinical cases. Why not use them as an informal consult for management decisions that involve ethical concerns? If we have learned nothing else in the last decade, we have learned that management decisions have a direct and measurable impact on patient safety. And the data are now there to show it. We’re being called to account—and bottom-line thinking is the place to start.

From a practical point of view

The research is clear that having fewer patients per nurse or more direct nursing care hours per patient day is associated with fewer adverse outcomes, in particular mortality, failure to rescue, and some specific adverse events, particularly among surgical patients. This association is no longer in dispute. Moreover, current efforts to tie reimbursement to patient outcomes (Patient Satisfaction—HCAHPS—and Value-Based Purchasing, for example) as well as a mandate to reduce hospital-acquired infections, also provide a rational for maintaining adequate nurse staffing, which indicates that “bottom-line” thinking will produce both negative patient outcomes and negative financial outcomes.

Leah Curtin, RN, ScD(h), FAAN, is Executive Editor, Professional Outreach for American Nurse Today.


  • Will the coming ‘fiscal cliff’ end up cutting Medicaid alltoments? Also, wht aboput the governors who won’t expand Medicaid and/or participate in the ACA?

  • I want to thank Leah Curtin for her insightful and informative columns!

  • I do not understand why people, especially health care professionals, do not realize that Government already pays for well over half of all health care costs, that governments funds well over half of all research, and that all of this happened long before Obamacare was introduced. If there is a government takeover of healthcare, it has already happened! Now it only remains to see to it that all Americans have acess to the care their taxes have paid for!

  • Government takeover of healthcare will only worsen the problems. The government does not operate efficiently and the assault on religious healthcare institutions (via the abortion, contraception, sterilization mandates) will “exclude people of conscience from remaining involved in the very institutions they created in the first place” (Defending the Free Market: The Moral Case for a Free Economy by R. A Sirico.

  • I believe that the purpose is to cut the “padding” out of institutional charges. I’ve often wondered how the largest hospital in my area could afford expensive publications, top heavy administrative positions with high salaries while cutting RN positions and substituting these positions with lesser paid, non licensed staff at the bedside.

  • My concern isn’t that the institutions will not survive. It’s the patients I’m worried about!

  • The ethics of the situation are the crux of the matter. If payment is to be based on the quality of care rendered, institutions cannot afford to have a “bottomline” mentality or they will not survive.

  • All of this may be true…but the pull of the bottomline will probably overome any research findings, and nurse will just be expetd to do more with less!

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