Celebrating our 25-year organizational ethics history

In April 1996, Harvard Pilgrim Health Care established an organizational ethics program.  At that time, Pilgrim Health Care and Harvard Community Health Plan, two physician-led, not-for profit health organizations had just combined.  The organization’s leaders recognized that virtually all organizational activities may raise ethical questions.  They designed the ethics program to help the organization:

• enhance its ability to identify and address the ethical dimensions of key policy, operational and budgetary decisions, in an effective and systematic manner,
• demonstrate to our members, internal and external stakeholders, and the public that the organization is actively concerned with ethical issues, and
• assure that the organization is prepared to address ethical aspects of issues that arise, with confidence that our processes withstand public scrutiny.

The central component of the ethics program is a quarterly Ethics Advisory Group (EAG) consultation that engages employees of the organization, network clinicians, employers, brokers, members, invited topic experts and representatives of the public. Leaders in the organization request EAG input on topics.  These topics are, by nature, challenging.  They generate discomfort, have no easy answers, and reasonable people will have differing perspectives.  EAG deliberations provide a format and structure for vigorous, open discussion, inviting a wide variety of voices, with the intent to answer at least one of the following questions:

1. What is the ethical issue in this situation?
2. What is the right thing to do?
3. What is the most ethical way to do it?
4. What ethical challenges can we foresee arising in the future?
5. What can we learn from actions in the past?

Three overarching perspectives guide the discussions: the organizational mission and values, values held by our external stakeholders, and external expectations for the organization.  Over the years, more than 140 deliberations have taken place, on topics ranging widely from serving members in a given market, to coverage of ever more expensive drugs, and the health plan’s responsibilities in mitigating health inequities that result from long-standing structural injustices in society.  Since the beginning of the Covid-19 pandemic, between 50 and 100 individuals participated in quarterly virtual EAG discussions.  Importantly, the EAG’s suggestions are advisory only.

The organization’s ethics program remains unique in the industry.  It is led by faculty in the Department of Population Medicine (DPM) in the Harvard Pilgrim Health Care Institute of Harvard Medical School and Harvard Pilgrim Health Care.  Dr. Jim Sabin, Professor in the DPM, co-founded the program.  Dr. Anita Wagner, Associate Professor, directs the program.  Through its faculty leaders, the program has ties to local, national, and international organizational and clinical ethics fora.  A 2003 publication from the Department, No Margin, No Mission: Health Care Organizations and the Quest for Ethical Excellence and a 2007 article in Health Affairs, Confronting tradeoffs in health care: Harvard Pilgrim Health Care’s Organizational Ethics Program describe the program. 

In a morally diverse society, open dialogue is crucial.  The 25-year history of EAG deliberations attests to the commitment of the organization to such dialogue.