The hospital as an ethical body

Gonzalo Herranz, departmentof Bioethics, University of Navarra.
lectureDelivered in Buenos Aires, 8 November 1999.
Published in Persona y Bioética 1998;2(3).43-67.

Index

Introduction

The hospital, victim of post-modern indifferentism

The hospital as a moral agent

Contents of Institutional Ethics

The ethical style of the hospital

The ethical brain of the hospital

Conclusion

Notes

Introduction 

It is a very interesting question as to whether or not the hospital is a moral organism with an ethical life of its own. And if the answer is yes, it would be important to determine to what extent a hospital can choose for itself rules to guide the conduct of those who work in it, how far it can go in its decisions in the face of the large and small dilemmas that are offered to it in the field of tensions of the prevailing ethical pluralism.

According to some, a hospital is a simple architectural structure, made of concrete and glass, housing and juxtaposing specific technical and administrative services, but completely devoid of moral convictions1. According to others, the hospital is much more than a building and general services: it is a dense network of human relationships which, over and above the physical plant, create a moral identity, i.e. always and inevitably carry within them an ethical purpose2.

What do the Codes of Ethics and Deontology of national medical corporations say? These same disparate conceptions of whether or not the hospital has an ethical existence are also manifested in the various ways in which the issue is addressed in the codes of professional conduct. Some of them recognise only the individual physician as the subject of ethical regulation. This is the most widespread attitude in professional regulations dominated by the individualistic modelof the medical internship, as is the case, among others, in Germany, the United Kingdom and France. Their Codes make virtually no reference to ethical issues specific to the hospital or to physicians working in health care institutions. When they occasionally refer to the hospital-based physician, as is the case in the French Code in its chapter on the salaried internshipof Medicine, it is to ensure that the individualistic modelis respected, i.e. that the leasing of professional services cannot harm either the independence or the individual responsibility of the hospital physician. The latter are not recognised as a moral entity, nor are they considered to have any specific relationships or situations that require ethical and deontological regulation that are not stipulated in the general contractual rules.

Other professional codes, on the other hand, devote one of their sections to the ethical regulation of the human and professional relationships created in the hospital. These relations of the physician with the hospital as an institution appear, for example, in their most general features in the Code of Ethics and Deontology of Spanish Physicians and, in greater detail, in the standards of the American College of Physicians3 .

The widespread reticence of modern codes contrasts with the detailed and meticulous regulation of the hospital doctor's conduct that dominates the medical ethics landscape of the 18th and 19th centuries. Percival's Medical Ethics is a treatise on the labeland ethics of hospital physicians, dominated by the notion that the medical gentlemen of any charitable institution are, to some extent, responsible for and guardians of the honour of the entire profession.

What is actually happening today? In my opinion, the workmedical market is a good observatory to see and describe this diversity of attitudes towards the hospital as an ethical institution. There is practically no workhospital market in Spain, but there is an abundant and varied one out there, and sampleshows how different some hospitals are from others. It is not uncommon for hospitals to discover their ethical identity in these advertisements, as it is quite common for hospitals to offer an institutional self-portrait, describing their self-image in a few strokes. There is no shortage of advertisements that merely list dataquantitative details of the hospital, give a list of requirementscurricula and degree programthat the candidates for the offered position must meet, and describe the technical functions to be performed. Hospitals acting in this way define themselves as purely administrative entities: for them, only their technical functions and their economic managementare important, while they remain silent about the ethical ideals and social commitments publicly professed and inspiring their activity. Sometimes the only human detail contained in these advertisements is a reference letterto the geographical environment of the hospital.

Another subjectof work, by contrast, openly declares that the hospital professes certain ethical convictions, and makes no secret of its desire that the candidates, in addition to possessing the appropriate academic and technical qualifications, should be endowed with a certain profilehuman and moral character. This is not only the case, as is to be expected, in denominational hospitals, which legitimately expect candidateto share the charitable mission statementof the institution, or at least to show a respectful and cooperative disposition towards the religious ideals of the institution. Many non-denominational hospitals, private and public, state as a requirement that candidates possess certain defined human and moral traits, such as a human personality of integrity, sensitivity in attentionwith people, ability to engage in the pursuit of excellence, availabilityfor workteamwork. Expectations sometimes go so far as to describe ideals that are not easy to achieve: A neurologist with outstanding professional and human qualities, with a personality inclined to cooperation, who does not refuse to serve on committees, and who is able to play a role in directing and financing research projects is sought. These advertisements also often tell us that the hospital, as an institution, has taken a stance on certain cultural and social issues: one advertisement states that, for equal qualifications and skill, candidates with a physical handicap will be preferred; while another states that the Talycual Hospital will favour the choice of female doctors in order to avoid job discrimination and to balance the proportion of women and men in its medical staff.

People wonder, and doctors wonder, how it is possible that a hospital can make such subjective decisions or decisions based on debatable preferences. It has to be acknowledged, however, that today it is almost commonplace - for reasons of party politics, regional preferences, or the simple pluralism prevailing in all areas of society - that few doctors and patients, health authorities and managers are at agreementon what should be done: everyone is influenced by their ideology, their professional commitments, their sense of life, their human project.

There does not seem to be a single answer to the question of whether the hospital can act as a moral agent, from entrance. In fact, many hospitals manifest themselves as entities endowed with an ethical conscience, while other hospitals prefer to remain in a limbo of institutional ethical indifferentism. Let us look at it in parts.

The hospital, victim of post-modern indifferentism 

Why are some hospitals ethically undefined entities? Ethical indefiniteness is the resultend of a process that can be arrived at by various routes. Different paths lead to indifferentism or corporate ethical pessimism, i.e. to the conviction that institutions, in our case the hospital, are beings, if not amoral, then incapable of endowing themselves with a valid institutional ethic.

One of them, culturally based, has been outlined by H.T. Engelhardt jr4. Applying his idea that, in ethically pluralistic cultures, strong ethical convictions no longer have any role to play in the world of public relations, but must be relegated to the realm of private conscience, Engelhardt, after acknowledging the private value of individual ethical opinions, points out that social institutions can no longer give themselves a coherent and rationally justified moral framework. There is no longer, either in religion or outside it, an independent, general, concrete moral perspective capable of mediating between different and conflicting understandings of moral integrity. Engelhardt includes in the notion of postmodernity the present historical statuscharacterised by the collapse of the hope of discovering who is the moral authority that can dictate the right answers to the great moral questions, or who could be the arbiter to settle disputes about what is integral and human. For a world marked by ethical pluralism, the metaphor of polytheism applies. There is no longer one God whom all must recognise and worship: there are only minor deities. In such a context, there is no longer room for the proclamation of a secular institutional ethic valid for all: ethical conviction retreats to the intimacy of conscience.

A position relatively close to Engelhardt's is that of minimal ethics, which is becoming widespread in Spain. It is described in the preamble to the Law on Assisted Reproduction5 as "an ethic of a civic or civil nature, not exempt from pragmatic components, and whose validity lies in an acceptance of reality, once it has been confronted with criteria of rationality and procedure at the service of the general interest; an ethic, in final, that responds to the feelings of the majority and the constitutional contents, that can be assumed without social tensions and is useful to the legislator in adopting positions or regulations". Here, instead of letting everyone choose their own deity, it is proposed that there should be a syncretistic, dominant and neutral idol that presides over social relations. According to this model, the ethical peace of the pluralist society will be achieved through ethical disarmament and the acceptance by all of a legalised ethic, in which one-dimensional people agree: ethical pluralism would not be expressed in the peaceful coexistence of different convictions, similar to a multicoloured and ordered rainbow, but in the acceptance of the new lowest common denominator of civil ethics. This would be like a grey supernatant that is produced by reacting with each other and precipitating what differentiates and singles out the different ethical opinions. What matters most is often not what is agreed, but the procedureused to agree it. It is the process that matters, not the result. What matters in each statusis what the majority votes, or the supermajority, a voting system used in some hospitals that requires certain matters to be approved by a majority of the doctors, a majority of the nurses and auxiliary staff, a majority of the hospital's management team. Under such conditions, the hospital could only aspire to a weak ethics, management assistant, consensus.

Toulmin6 describes another, sociological, way for the hospital to reach institutional anomie, for whom the withdrawalof projectto provide itself with an institutional ethical commitment is resultof a historical process of progressive rarefication of the ethical atmosphere of the corporations. Developing ideas from Émile Durkheim and Max Weber, Toulmin speaks of the suffocating effect that excessive centralisation management assistanthas on the spirit that animates the hospital, leading to a de-moralisation of those who work there, a terminal impoverishment of ethical values: the generous and creative professional vocation of voluntary duties is replaced, after years of disenchantment, by the routine fulfilment of the functions of position; ethical duties are absorbed in bureaucratic imperatives and control mechanisms; individual responsibility is replaced by institutional evasion: the regret for the error staffis dissolved in the collective excuse. The hospital is thus turned into a place where not men but human shadows work.

The hospital as a moral agent 

The vision of the hospital as an ethical no-man's house is opposed by the idea of the hospital as an ethical entity. It is now de facto and peacefully accepted that there are hospitals that clearly state that they are not indifferent to subjectethics, that define themselves as being driven by an institutional mission statement, that adhere to certain modes of conduct, that wish to recruit some doctors and nurses in preference to others on the basis of certain selective criteria of a psychological and ethical nature, and that state that they aim to achieve certain ideals or to object to certain actions.

What legitimate reasons have been offered in favour of hospitals, private and public alike, professing an ethical creed? Although the theoretical foundation of the hospital as a moral entity has been relatively little studied, there are some very rich doctrines programs of study.

Pellegrino and Thomasma7 have been the first to develop thesis that both hospitals and medical teams should have an institutional ethic of their own. Such an ethic includes not only the individual relationships between doctors and patients and those of individual doctors with each other. Hospitals, as an institution, need to be moral persons, which implies, on the one hand, that they act as conscious, explicit and sensitive moral agents, and, on the other hand, that they proclaim this to society. They must be moral persons and do so not only to prevent the danger of living in anomie or moral confusion, but also to prevent the risk of being distanced from their humanitarian goals by internal tensions (power sharing, excessive profit motives) or external pressures (from subjecteconomic, political or fiscal).

Such collective ethical convictions must necessarily be compatible with respect for the legitimate ethical pluralism of individuals (patients, doctors, nurses, administrators, employees and managers). But they must also be strong enough to show that the hospital is animated by an ethical personality, a first person plural, a we, which is an active moral subject, which, over and above the minimum requirementsrequired by law, professes certain human ideals, follows certain professional models, and assumes certain voluntary responsibilities which are, so to speak, the defining marks of its institutional identity.

According to Pellegrino and Thomasma, an atomistic, distributive modelof collective action, according to which the total action is the simple arithmetical sum of the separate decisions of its individual members, does not apply to the hospital. The hospital, as an ethical business, needs a non-distributive model, in which the action of the whole cannot be reduced to simple individual decisions, but requires the ethically co-ordinated action of all, as group, who assume professional ideals.

Being a moral agent admits different Degreesor levels. Thus, the group of doctors, nurses and auxiliaries who provide concerted care to a patient, in addition to being a technically coordinated team, must act as a single moral agent. And the governing bodies and medical services must also act as an operational unit when they interactively discuss and reach decisions, strongly charged with an ethical accent, on efficiency, equity and fair distribution of resources for the best service to patients.

Pellegrino proposes that the necessary ethical personality of the hospital stems from the nuclear and founding fact of medicine. This is the human and ethical response to the vulnerability of the sick person. Above and beyond the ethical minimum required by law, the hospital must respond humanely to the needs of the sick, as human beings afflicted by illness, with a modulated ethical conduct, a deontological ethics of obligations. It is the sick person himself, in need of financial aid, who imposes on the hospital the obligation to commit itself ethically and to adopt moral attitudes as a living and sensitive ethical organism.

Another author, De George8 , analyses the moral responsibility of the hospital on the basis of a phenomenological analysis: the hospital is not a hotel with special instrumental equipment. It is, rather, the whole, made up of those who work in the hospital and run it; also of those who are ill and come to it; and, finally, of the services and facilities that they use and occupy. This complex and structured organisation has an existence that is prolonged over time and does not depend on the individuals who constitute it at any given moment. The hospital develops and changes, grows or falls into stagnation. It is, from a legal point of view, a legal entity, but its existence is independent and goes beyond the legal.

What is specific to the hospital is, for De George, that it consists specifically of an entity endowed with moral life. This is how people understand it, who take it for granted, as a matter of common sense, that the hospital is morally active. We rightly say that a hospital does things well, that it has good operating standards, or that it treats people well; and also that it is in debt, or that it is a factory of pain. Even if we do not know the name of the doctors working there, we choose or reject it because it is efficient or has little prestige. And so, the usual thing to say today is: I prefer to go to Hospital So and So; or: I wouldn't have surgery at Clínica Cual for anything in the world. Hardly anyone says: I would like Dr. A to operate on me; or: I am terrified that Dr. C will treat me again.

De George rightly points out that many of the actions of administrators and doctors are not attributed to the individuals who perform them, but to the hospital. The General Managerwho orders supplies commits the hospital to pay for them. The surgeon operating in a hospital's operating roomis performing a function of the hospital, since he not only uses its facilities, but also relies on the significant and indispensable financial aidof staffhired by the hospital, before, during and after he performs the surgery: his operation is inextricably part of a set of actions (by staffkitchen and cleaning staff, maintenance and administration, clinical archives or assistants operating room) that always involve an ethical responsibility.

Hiller and Gorsky9 have paid attention to an interesting aspect of the ethical identity of the hospital: the history of the internal discussionbetween physicians and administrators as to who should define and proclaim the ethical identity of the hospital. In the early decades of the modern hospital, administrators were seen as a mere extension of the physician, thus subject to the same ethical standards. In the United States, there was for a long time a single code, a Hospital Ethic, common to both administrators and physicians. But a couple of decades ago, the old harmony broke down when financial problems began to create tensions between the two. The new morality management assistant, which demanded reducing costs and optimising profits, and the traditional morality of unlimited service of the doctor to the patient, so typical of Hippocratic-inspired ethics: I will do what I know and what I can for my patient, became progressively incompatible. This led to the ethical divorce of the two guilds: both the association, which brings together hospital doctors, and the , which brings together hospital administrators, chose to have separate codes. The code of the administrators, while recognising that the primary role of the hospital administrator is to care for the sick and to provide them with quality medical care, establishes economic imperatives almost exclusively in order to achieve the necessary match between the cost of the services provided and the resources available. The traditional charitable orientation has in many places succumbed to economic imperatives.

There remains, however, a widely held view within the ranks of hospital administrators that recognises that the hospital's mission statementand its institutional ethos must prevail over economic imperatives. Kurt Darr10 has argued very strongly for the need for each hospital to define its mission statementand its Philosophy, otherwise it would not be possible to establish an organisation, since mission statement, values and principles are the subjectprima from which rules and objectives are derived: they are the reference letterfabric of that allows for the choice of ends and means. Corporate culture and institutional personality, which are born of shared values and purposes, define the institutional ethos necessary to achieve corporate effectiveness. Darr points out that one of the most important sources of conflict in organisations is the reluctance of those who do not share the common ideals to express their dissent and to form internal resistance groups.

What happens in the real world confirms this view. Occasionally, in the course of the ordinarily peaceful running of the hospital, a patient or a member of the hospital raises a statusthat others consider unacceptable on ethical or scientific grounds. The first reaction of those who feel limited in their aspirations is to appeal to what they assume to be their natural advocate: to the director of the hospital. This simple fact imposes an unavoidable conclusion: the hospital as an institution, in the person of its director, cannot avoid speaking out as a moral agent. Assuming today's open and democratic society, ethical conflict and the normative and procedural resources for its solution are an essential component of the hospital. Institutional moral abstentionism is impossible.

Contents of Institutional Ethics 

Although hospitals are moral agents, they are not human beings. They act to the extent that those who work in them act. The moral responsibility of the hospital is collectively assumed by many, it is distributed among them. It is a heterogeneous and multiple responsibility, subsidiary but compatible with the individual responsibility of each person. This is defined by the position that each individual occupies in the whole, the function he or she performs, the hierarchical rank assigned to him or her, and, finally, by his or her simple status as a citizen.

There are different ways of defining, exercising and sharing collective moral responsibility: it may be attributed to one, several or all individuals, depending on the different models of management. But it includes, in any case, first and foremost certain fundamental commitments that make up the mission statementthat the hospital sets for itself. Over and above the legal rules on good clinical internshipand on the quality of medical services, over and above the clauses of the Charter of Patients' Rights, each hospital must define the intensity with which certain voluntarily assumed rules concerning, for example, ethical respect for the patient must be lived within its walls, attention teaching for medical and nursing students, the maintenance of Education, the scientific research, the social insurance offered to those who work there, or the permanent renovation of the physical plant and medical equipment.

Institutional ethics thus consists of a defined set of obligations that transcends the individual opinions of the individuals - doctors and nurses, administrators, managers and promoters - who work in and run the institution. Each health care institution must decide and make known to the community in which it resides its moral creed: whether or not it sanctions absolute or limited ethical pluralism; whether, in this or that ethical conflict, it adopts one specific attitude in preference to another, by virtue of its religious or professional commitments11.

Given the ethical and professional pluralism present in today's democratic society, institutions must decide their moral choices and publish them explicitly and clearly. Hospitals established and run by religious bodies have been doing so through their ethical directives on certain interventions, which are binding. Civil hospitals should also do so with regard to, for example, whether they admit or reject certain forms of alternative medicines, whether they offer terminal care, what procedures they apply in selecting and appointing their physicians and in appointing those who run services and sections, the role of professor, whether they reject abortive operations, how effective they make patient information services, their attitude to biomedical research, the advertisinggiven to recommendations and criticisms that may be made by the hospital's Medical Commissions, and many other things.

Ideally, in a democratic society, there is a tendency to balance the ethical pluralism of citizens with institutional ethical pluralism. Hospitals should therefore have a moral face that is as public, known and distinctive as their physical façade. And while there may be some disadvantages to this, the advantages would be greater: as Pellegrino and Thomasma argue, people would be less disappointed by institutional ideals that are sincerely stated, if only imperfectly achieved, than by their concealment or indeterminacy for pragmatic, cynical or simply financial reasons.

The ethical style of the hospital 

The publicly proclaimed ethical commitment and the publicly announced institutional ideals should be taken into account on a daily basis by those who work or are cared for in the hospital. Whether they are carved on a marble plaque on the main entrance hallor simply printed on sheets of paper, the important thing is that the ethical credo of the hospital influences the conduct of all, until it crystallises into the peculiar way, the particular and determined style of practising medicine that the hospital has adopted and maintains. The timely and gentle reminder of these ideals should be one of the most cherished functions of the leadership.

There are many and varied manifestations of this human style in which institutional ethics crystallises. I will mention here a few as an example sample.

Recognising and correcting mistakes. Decisive for the ethical life of the hospital is its corporate attitude to the mistakes that are made within it. It is inevitable that many mistakes occur in the hospital every day: unforeseeable accidents, unintentional oversights, negligence of greater or lesser degree. Those who work in a hospital that has decided to lead a sincere moral life will not hide their own mistakes as negative and harmful, but will recognise their potential benefit, both for themselves and for others. For recognising, confessing and analysing the accidents, mistakes or negligence committed not only serves to prevent their repetition: it creates an atmosphere in which it is possible to work with greater and sharper responsibility in an atmosphere that is also more sincere and trusting.

A study conducted in the United States12 on the epidemiology of harms induced by medical interventions, so-called adverse events, has shown that these harms are not randomly distributed: certain hospitals have fees(both gross and negligent harm) ten or more times higher than others. This findingseems to lend strong support to the view that it may be the system, rather than the individual, that is the main cause of this specific accident rate, and that it is therefore the system, and not only individuals, that needs to be analysed and reformed.

There are thus institutional factors responsible for the leavequality of care provided in some hospitals: among these, some have been identified, such as the hospital's poor collective self-image, lack of corporate moral energy, poor communication among its members, lack of clarity about institutional goals, recurring periods of crisis triggered by chronic problems, which take time and delay to be solved. There are hospitals with high morale leave.

To correct its mistakes, the hospital does not only need technical Structures, mortality committees subjector performance audits. It needs to mobilise its ethical reserves. purposeEach hospital should have a specific written requestto analyse ethically the accidents, errors and negligence that occur in it, especially those that tend to be repeated, with the aim of developing standards for the prevention of iatrogenic harm13. McIntyre and Popper have postulated the need for today's doctors and hospitals to change their attitude towards the mistakes they make: they must not hide them, but manifest them; they will not limit themselves to condemning them, but should use them as an instrument educational; they must discuss them, not to punish those who make mistakes, but to improve the conduct of all14. Such a change of attitude is, in my opinion, a basic element of the institutional ethics of the hospital.

Proclaiming and practising human rights. All countries respectful of civilised coexistence have subscribed to the Declaration of Human Rights and others that apply the general doctrine to various cultural areas. The World Medical Association associationhas translated these general human rights into a charter of specific patient rights. Moreover, legislation on the rights and duties of hospital patients has been introduced in many countries.

I believe that it is an elementary part of institutional ethics for all those who work in the hospital to recognise the rights of patients, together with a sincere commitment to always respect them and never to deny or violate them.

Moreover, the ethically committed hospital, which truly wants to treat the men and women who come to it with due dignity and respect, must set up on internshipan active system to inform patients about their specific rights and duties and to listen to their legitimate requests.

Improve Internal Communicationsand with the outside world. A hospital is a dense web of human relationships, a hive of communication. Poor communication makes the hospital a strange, labyrinthine world in which the patient becomes disoriented and lost. It is therefore very important for patients and visitors that the hospital is well signposted, and that when they ask for information, they are treated with courtesy and sympathy, not rudeness and impatience. When questioned, the countenance of those working in the hospital should not express cynicism, bitterness or disappointment15. A hospital will never be brought before a judge for neglecting these elementary rules of courtesy. And yet, none of those who work in the hospital should forget that any unwelcoming and impatient or even hostile behaviour is particularly traumatic for those who are going through the difficult crisis of illness in a strange place.

Communication failures in British hospitals have recently been classified by the British Audit Commission16 . Surprisingly, but perhaps accurately, the Commission has concluded that the prevailing unsatisfactory statuscan only be remedied if senior doctors and managers can realistically understand what it is like to be admitted to their hospital. To do so, they would need to put themselves in the shoes of their patients, listen to their experiences and complaints, listen to those accompanying them, and seriously investigate the problems revealed. The leavequality of communications within the hospital is the cause of much gratuitous suffering. Improving such communications should be a collective ethical goal.

Good external hospital communications are also an institutional ethical duty. The hospital cannot be a self-enclosed structure that lives with its back turned to the surrounding medical community. Hospital physicians cannot ignore their colleagues outside the hospital. Communication between hospital doctors and general practitioners is one of the weakest and most contentious points in the entire modern health care system17 , and a cause of much harm to patients, and of deep discomfort to doctors on the street. The Professional Code of German Physicians, for example, states in § 20.3 that "on discharge from hospital, the patient must be referred back to the general practitioner who attended him before his admission to hospital". But such a rulewould be reduced to a vain formality of professional labelif the hospital doctor did not send a discharge letter to the treating physician as soon as possible which, in addition to the relevant information on the patient's stay in hospital, invites mutual cooperation in the follow-up of the patient18.

The professional and ethical quality of a hospital can be measured by the quality of the discharge letters its physicians send to their primary care colleagues. And the reason for this is easy to understand: hospital doctors have a duty of exemplarity towards other medical professionals. It is not for nothing that it is in hospitals, and especially in teaching hospitals, that the lex artis, the correct way of practising the profession, is created, verified and confirmed. This includes not only diagnostic and therapeutic innovations, but also the ethical dimension of the internshipprofessional. The conduct of hospital doctors has, for better or worse, a contagious effect on the behaviour of general practitioners.

The ethics of workin a team and of the hierarchical function. The hospital is a privileged ethical place, which, thanks to workin a team, fosters the moral growth of those who work in it. The ethics of workteamwork seeks to preserve intact the independence, and consequent responsibility, of each member of group, while creating shared ideals and horizontal and vertical relationships that multiply efficiency and divide effort. Relationships, hierarchical or not, within groupmust be compatible with and protect the professional and human dignity of all its members.

The workin a team must be based on individual responsibility. The moral independence of the physician does not disappear or is not diluted by the fact of working in group, says the Spanish Code. The ethics of individual responsibility is universal and applies to all forms of professional practice. In all circumstances, the physician retains, with his independence, his freedom to prescribe. He may never act as an anonymous being in front of his patient. To symbolise his responsibility staff, he will sign his name to the entries he makes in his patients' records and to the orders he prescribes for them.

The contracts by which physicians lease their services to a hospital must make clear the criteria for obedience and freedom. There cannot be masters and serfs, employers and mercenaries in hospital medical teams.

Hierarchical organisation is an ethical necessity, as it is the legitimate way to create order and efficiency in a groupof people who have to work together. Today, fortunately, the hierarchical function tends to be based more on prestige than on power. Those who govern must win the support of the governed on a daily basis, through the exercise of moral and scientific authority, the ability to work, rationality in what is ordered and respect for subordinates. Authority must be conceived as a service to others, not as an occasion for despotic domination.

Respect for ideological diversity is an essential element of a good hierarchical management.

Taking care of the little things. It is interesting to note that the judgement patients and their relatives form about a hospital is not based solely, and often not primarily, on the high technology available to them, on the scientific skillof their doctors, or on resultfavourable of their more or less spectacular interventions. People's judgement of hospitals is decisively influenced by seemingly irrelevant details, but to which patients and their relatives attach a great deal of importance.

This is logical, as the little things are a sincere, realistic and not easy to falsify sampleof the institutional ethos, of the spirit shared by all. What degrades or dehumanises the hospital is not the commission of an isolated serious misdemeanour, or of an occasional mistake, which can be committed by anyone who works there. The ethical environment does not deteriorate as a result, because on many occasions, a glaring mistake is a warning message that triggers a life-saving response. The hospital as a moral entity decays when it develops a chronic carelessness, a collective indifference to small things that should be corrected, but which no one seems to care about.

These are seemingly irrelevant things. One of them, to pick one, is the care of the hospital's environmental quality. We all agree agreementthat a hospital is morally obliged to establish, for example, rules on the proper use of antibiotics, to have an effective and rapid fire safety system, or a programme for the destruction of hazardous waste: it is not acceptable for a hospital to carelessly promote the developmentof resistant bacterial strains, to be indifferent to the prevention of catastrophes, or not to care about polluting the environment.

But not many people think that the hospital has to make a great effort, for example, to take care of what could be called its sensory ecology: noise, unpleasant smells, unpleasant tactile stimuli. The hospital, as an institution, is meant to be a welcoming and soothing place. It would gradually degrade as a human environment if it did not feel responsible for reducing the sensory aggression that seems to be the inevitable companion of technological progress. Grumet19 has described very accurately the noise pollution of the modern hospital, which, without exaggeration, he describes as pandemonium. When noise exceeds a critical level, it acts as a pathogenic stimulus, disturbing patients' rest, reducing the attention span of doctors and nurses, and exerting a stressful effect on everyone. It creates, in particular, an environment lacking gentleness, where loudspeakers and people compete to be heard, where conversation and orders are given too loudly, instruments are used roughly, heels are walked on, shouting is heard from one end of conference room to the other. It has been observed that, along with work pressure, the sensory overload present in the wards and corridors of many hospitals strains the nerves of staff: quarrels are frequent and unmotivated, calls are not answered, good manners are abandoned. What is more serious: an impersonal atmosphere of mutual detachment, disinterest, and anonymous dilution of responsibility is created, similar to the 'norms of reticence' or 'small radius of sympathy' which have been described as characteristic behaviours of inhabitants of very large and noisy cities.

Many sick people react to environmental clutter by taking refuge in the even louder world of television. Today, television sets are the sourcemain source of noise in hospital rooms. Inpatients seem to enjoy an uncodified right to watch and listen to television without time limit. For many, the television set has become a faithful companion, refractory to fatigue, accompanying them through the long hours of solitude during the day and prolonged sleepless nights. But what is company and solace for some is torment for others: in multi-bedded rooms, patients who want to rest or sleep are often forced to cover their heads with pillows or blankets in order to protect themselves from the glare of the portable television sets used by their roommates. It would be very interesting to study the use of the television as a substitute for the frequent absence of familiar warmth and friendly attentionexperienced by many hospitalised patients.

Noise pollution, odours and irritating stimuli must be eliminated as a matter of urgency. Like much of what is most valuable in a hospital, this is a collective business, which concerns and involves everyone. Caring for the sensory ecology is part of the hospital's basic ethical commitment.

A hospital worthy of the name should be hospitable, gastfreund. And so should each and every one of those who work there. None of them is inferior. From the point of view of work, in a modern hospital, the workof those who do the housework of cleaning, washing up, or preparing meals is just as important as that of the "star" teams of doctors who carry out the most advanced researchprojects or the most sophisticated and spectacular diagnostic or therapeutic interventions. The same applies to the ethical function: the improvement of the human quality of the hospital as an institution can only be achieved through the contribution of highly motivated people working in all trades and tasks and at all levels of the functional and hierarchical organisation20.

A hospital cannot neglect the acquisition of new and high technologies: but it should not forget that the bed is the most universal and most used medical instrument. The hygiene and comfort of the bed is an indicator of the human quality of the hospital and one of the obligatory manifestations of the hospital's respect for its patients. The modern conception of the human dignity of the body, in which the body is recognised as the substrate and real manifestation of the person, would be an empty theory without attention to the details by which the body is accorded the respect it is due. Nothing is more humiliating than to be lodged on a poorly sanitised mattress, which exhales vapours of excreta left there by an incontinent patient who had used it before21 . And, by contrast, nothing is more gratifying for the patient than to feel the caress of freshly changed sheets: it is not just a pleasant tactile perception, but a sensation that combines bodily well-being with the awareness of being recognised as a person, a holder of dignity22 .

The ethical brain of the hospital 

In order to remain ethically alive, the hospital needs an institutional ethical body that can grasp problems, study them, teach them and respond to them. This ethical body can, in principle, take various forms: it can be a concrete, formalised structure, such as a more or less complex institutional committeeor a simple one-person consultancy service; or a diffuse, unofficial, but active and influential body.

The structure and function of such committees and consultancies, as the proper bodies to advise in difficult dilemma situations, are not of interest here. The moral life of a hospital is not sensibly enriched by convoluted ethical rulings on borderline or exceptional cases. Of far greater ethical efficacy is the creation and transmission of the ethical style, traditions or habits of action characteristic of each hospital, relating, for example, to how the daily ethics of the doctor/patient relationship is lived by all: the loyal and dignified attentionwith the sick, the availabilityto listen to them, the promptness with which their calls are answered and they are informed before they ask, the availabilityto accede to their reasonable requests, and the firmness with which their capricious or irrational pretensions are rejected.

Also part of these institutional traditions are the ways in which physicians live their loyalty to the hospital and its governing bodies, to their colleagues and to their subordinates.

These little things should be included in the diaryof each hospital's ethics committee. The agendaof the institutional ethics committees should not only be nourished by jurisprudential cases or the dramatic clinical episodes to which we are accustomed in American bioethics: it should also include questions of everyday good conduct in order to gradually shape the hospital's ethical style through relevant recommendations.

Hospitals need to discuss medical ethics, just as they discuss clinical pharmacology or new technologies; they need to raise certain deep-rooted oversights as ethically problematic; they need to search and analyse bibliographyto find out what solutions others have given to a similar problem; they need to decide, with the help of partnershipof those who wish to intervene, on the criteria that seem to best represent the ethos of the institution. Just as a hospital, in order to have an intense professional life, needs clinico-pathological sessions, service audits and mortality conferences, it also needs, in addition to the error analysis meetings mentioned above, clinical ethics sessions. It is essential that someone has the time and resources to provoke ethical reflection, disseminate information, and raise awareness, so that the hospital can complete the stages of moral developmentthat every institution must go through from the stage of an amoral corporation to that of an ethical corporation.

Conclusion

It is very important that everyone, doctors and patients, authorities and administrators, ensure that the hospital is an ethically committed institution, a servant of life and of mankind. Along with the school, the court and the church, the hospital must be a focus of humanisation, a privileged place where people grow in dignity and become truly human. This function of ethical leadership towards the surrounding community can never be achieved if the hospital chooses to be ethically a nobody's house. It must be a common home, where men and women with serious ethical and scientific commitments, shared and publicly manifested, seek to exercise their professional vocation of service to the sick.

Notes