Legal & EthicsPractice MattersWorkplace Management

How do we get into morally questionable situations?


One of my most favorite books is Laura Nash’s Good Intentions Aside: A Manager’s Guide to Resolving Ethical Problems (Harvard University Press, Boston, 1990). In thumbing through the book a few days ago, 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 average 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) …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)…

Francine Gaillour, MD, writing for HealthLeaders News in August 2003, opined that we get into morally murky situations for three major reasons:

“1. Some physicians and executives really do want to reach as far as possible into ‘deep pockets.’ When I was a second year resident, I was stunned to overhear a particular conversation among my fellow colleagues-in-training. This ‘strategic’ conversation was about what their ‘gimmick’ would be when they left residency and entered practice. A ‘gimmick’ was the term for a high-fee billable procedure…

2. Some of us aren’t paying attention as the veil of ‘ethical flexibility’ is lowered over our eyes. As humans, we all run the risk of succumbing to a common phenomenon: ‘ethical flexibility…
3. Leaders aren’t doing their job of modeling organizational values and desired behaviors… When situations get ethically murky, look first to your leaders…”

I would add the following signs of danger to this list:

  • Cutting staffing to save money
  • Down-staffing to save money
  • Making light of the need for ongoing quality improvement activities
  • Diluting the mission of the organization from giving care to “giving cost-effective” care
  • Bottom-line thinking in health care.

As Nash and Dr. Gaillour have so eloquently expressed it, bottom-line thinking is both pervasive and destructive. However, while it is clear that bottom-line thinking in business has many serious implications, bottom-line thinking in healthcare organizations creates an atmosphere that can honestly be described as lethal. All the safety panels, commissions, and experts that have been created and consulted in the last 2 decades cite the need to emphasize competence and integrity—and definitely to de-emphasize the bottom-line! The problem, as Nash explains, is to acknowledge the reality of bottom-line thinking in your own organization and to develop ways of recognizing when the pull of the bottom-line is overtaking common decency. And then, of course, you need to do something about it. What follows is a short list of realistic ways of countering bottom-line thinking:

1. Look for moral paralysis on a personal level: Bottom-line thinking is the most common excuse for doing nothing, seeing nothing, and saying nothing.

2. Look for moral indifference on the organizational level: A great many ethically murky situations are created by bottom-line justified changes.

3. Set forth a framework of questions to ask yourself and to discuss openly with your team: Bottom-line thinking blinds us to an honest analysis of any situation. To begin to break that cycle, make it a policy to ask:

  • Who might get hurt (besides us) if we choose this particular course of action?
  • How is the problem being defined? When the discussion is framed primarily in terms of the organization’s needs, bottom-line thinking has taken over again. Reframe the discussion in terms of all three stakeholders: patients and families, personnel, and then the organization—in that order of priority.
  • What language are we using to set targets for other people? When you choose bottom-line language (profit as priority, do more with less, organization-comes first), you promote bottom-line behavior that communicates to employees what you think is important and what you will reward. An emphasis on safe care, safe working conditions, and high levels of competence refocuses thinking.
  • If this decision were to be published in the local newspaper, how would it affect the reputation of our facility? Any time decisions are made on the premise that no one is going to know (think: find out) about them, you are in ethical deep waters. This is an unmistakable sign that a decision is wrong, and everybody knows it whether or not he or she has the guts to say it.

4. Do not limit your ethics committee to clinical situations. An independent, confidential, and multi-disciplinary committee is likely to spot moral deficiencies in proposed plans. So, when in doubt, you can ask the ethics committee, and their decision should be as binding on management as it is on clinicians.

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. We’re all being called to account, and eliminating bottom-line thinking is a great place to start.

Leah Curtin is Executive Editor, Professional Outreach for American Nurse Today.


  • There is so much to say! However I will address the problem of the nurse who wrote on April 12th…The answer is simple to say, not so simple sometimes to implement, but it is this: A clinical judgment should be influenced by the patient’s clinical status — and not by his/her economic status, whether rich or poor – or in between!

  • As a hospital nurse in a state that is not nurse friendly, bottom line thinking is the norm.The area I live in has a high non paying population. I treat everyone the same.Certain people (with money,insurance or influence) were highly catered to the point that nurses were afraid to tell them basic instructions (taking a shower getting out of bed,etc) for fear of a complaint. Any problems,concerns or complaints from this population are weighted high while others are ignored.Huge ethical dilemma.

  • I love this article. As a current student in the nursing program, I find it incredibly important to watch my own code of ethics. I have heard many questionable things in the hospital settings that call into account the morality of situations. I particularly agree with how bottom-line thinking may be the uprising problem. “Cost-effective” care is not always the best care, and I can only hope I can continue to hold my own morals up higher than the idea of cost-saving efforts.

  • However, this article has to do with helping people determine for themselves what’s right in the situation in which they find themselves.

  • Pat has a point: morality involves choices that affect only oneself. Thus, right and wrong moral choices are determined by the person making them. Ethics involves choices that affect others, and certainly concern those affected as well the community at large…From a narrow perspective, it’s why we have professional ethics; our decisions, made in that role, affect others more than themselves, and because we can’t practice without the public’s trust, our peers also judge what’s right & wrong.

  • …And who is to say what is morally questionable for someone else?

  • To the reader who asked about the old Curtin and Flaherty Ethics Text…There are no plans to do so (Josephine Flaherty is not well), but I could do so if there was a real demand. The fundamentals remain the same, but the case studies need updating — as do many of the issues we face today. I’ll think about it, and thanks!

  • Leah, reading this article had me longing for a new edition of the old Curtin and Flaherty Nursing Ethics text book.I used to teach a 3 credit course based on it.Any plans to update it?

  • Psych NP Dallas
    February 12, 2014 3:14 am

    In school I had a preceptor with her own practice. (She hired her MD). She had this Energy machine. The patient sat in it and somehow it balanced your energy. It was something like $110.00 to use this. I am a pretty western thinker. I felt sorry for people who came in fully believing in this snake oil. I understand the power of belief. Invest money into some crazy idea and placebos work. It worked for many people; but then did the “blue pill” back in the late70’s

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