Ethical issues are usually expressed as a conflict of ideas, values, and/or norms that are often role dependent. It should therefore be expected that ICU physician directors and nurse managers, who have both clinical and non-clinical duties, should face some of the more difficult moral conflicts in the ICU. In one respect, these professionals follow a patient-centered code of conduct, either the Hippocratic oath or the Nursing Professional Code, which in part defines them. At the same time, they are also agents of the hospital as 'a business', and implicitly society as a whole. Although some clinicians completely relinquish their clinical duties on transition to management, most do not; the professional nature of medicine therefore gives the clinician a patient-centered outlook that is not as easily set aside: once a doctor or nurse, always a doctor or nurse. In summary, the physician director and nurse manager will always be in the unique position of having two separate professional standpoints from which to assess situations, which can therefore lead to unique ethical challenges.
We have begun to characterize the scope and uniqueness of ethical issues that are raised by the dual roles of clinician–managers in the ICU. In reviewing the health literature, we found that almost half of the articles identified that discussed ethical concerns for ICU clinician–managers were concerned with resource allocation. This is probably not surprising given that ICU clinicians are increasingly adopting the role of economic rationalist . Perhaps the real surprise of these results is how many articles concerned issues other than resource allocation. Although DeVita and colleagues pointed out that 'end-of-life' was not the only ethical concern in the ICU , which they took to be a common assumption, we argue that there is more to the ethics of directing roles in the ICU than issues of resource allocation.
In this initial survey of the ethical issues experienced by those in dual management–clinician roles in the ICU, important to our conclusion was the development of a categorization scheme. In the absence of any unique approach, we were arbitrary in our definition of categories. Although some of the articles we identified could have been placed in more than one category, or in categories not used, we believe our approach to be valid for the modest purposes of this survey. Additionally, some articles that discussed issues of clinical ethics in the ICU might have contained less prominent opinions or notes relevant to clinician–managers and therefore might have been missed by our search. In spite of these potential issues, the articles selected were distributed to give both a clear and defined picture of what currently exists with regard to ICU ethics for those in both clinical and directing roles at the same time. We also believe it is likely that there were many articles that discussed ethical issues relevant to our review, yet failed to recognize the issues as being 'ethical' in nature. For example, many articles described the nuances of resource allocation in the ICU (see the Introduction), yet neither mentioned ethics or recognized any uncertainty with regard to the 'right' thing to do. The fact that many articles fail to address their ethical components might indicate a lack of awareness of what constitutes an ethical dilemma, but even if this is not so, the goal of better recognition and acknowledgement of the ethical issues that suffuse the operational management of the ICU is desirable.
Resource allocation is a well-defined topic of ethical interest that has stimulated much discussion. However, it is important not to perceive resource allocation as the beginning and end of the ethics discussion for clinician–managers in critical care. Perhaps it is also time to move beyond the commentary on resource allocation and devote more research initiatives toward this topic (for example by studying the different approaches to resource allocation).
The term 'organizational ethics' is used to denote how a business or institution ought to be organized in any number of ways, including management functions, working environments, and its infrastructure. It should not come as a surprise that organizational ethics should constitute a concern for either an ICU director or a nurse manager, yet over the past 20 years only a handful of articles have been written about the organizational ethics of intensive care and have recognized them as such. Although policies and protocols for an ICU could also fall under the heading of 'organizational ethics', we believe that determining and implementing policies might require ethical concerns that merit special attention. The use of any policy that deals with either patients or staff is to apply one rule to many different people, and necessarily ignores factors that make individual cases unique. Because policies tend to generalize in this way, they create unique ethical challenges. Little reflection is required to determine that both of these issues, organizational ethics and the ethics of policy, constitute ethical concerns for directors in the ICU in which further study is merited.
The role of the ICU physician director, or nurse director/ manager, is an ethical issue itself. Although two articles were identified that addressed this issue, we believe that the paucity of articles found indicate a need for greater consciousness of the ethical factors that influence and are influenced by clinical leaders in the dual roles of 'clinician' and 'manager'. Although healthcare leaders are familiar with the importance of ethics, they may be unaccustomed to thinking of their own role in terms of ethics . Because the ICU director, or nurse manager, may engage in the decision making process from multiple professional standpoints (as both clinician and manager), the likelihood of conflicting rational and justifiable solutions, leading to ethical dilemmas, increases. The clinician–manager role, then, may require a higher level of ethical proficiency, or perhaps expertise.