Application of the Concepts of Social Responsibility, Sustainability, and Ethics to Healthcare Organizations

Introduction

Corporate social responsibility (CSR) is a concept that has gained much attention in the last decades, as it became an important issue of research in social sciences and therefore leading to rich and diverse publications.^1,2 In fact, CSR has been a growing source of debate as its forms and practices vary significantly between firms and encompasses a wide variety of fields. Currently, in addition to ethics, this concept of social responsibility is increasingly considered in the context of healthcare delivery suggesting a new paradigm in hospital governance.^1,4,5 Sustainability is another emerging strategic goal for healthcare systems and organizations as their development relies on implementing and strengthening sustainability as a crucial principle driving health sector to create public value and benefits in order to promote both health and wealth for people and society.^6,7

We briefly discuss in this paper the application of social responsibility, sustainability and ethics to healthcare organizations.

Corporate Social Responsibility (CSR)

CSR is a concept that has varied through history. In fact, formal writing on this topic is a product of the past 70 years.¹ In the landmark book of Howard R. Bowen Social responsibilities of the businessman, published in 1953, large businesses were considered as centers of power and decision-making whose actions impacted the lives of citizens. He, therefore, set an initial definition, according to which, CSR refers to the obligations of businessmen to pursue those policies, to make those decisions, or to follow those lines of action which are desirable in terms of the objectives and values of our society.^1,2

Between the 1950s and 1970s, CSR took the aspect of pre-corporate philanthropy, a widely divergent approach involving support for national non-profit organizations at the discretion of CEOs with little transparency.^1–7

Definitions of CSR began to develop and proliferate considerably in the 1970s and became more specific on the business and public relationship. In the 1980s, strong foreign competition and a bigger concentration on shareholders led many listed companies to adopt stricter quality controls. This triggered higher demands in order to link corporate philanthropy to financial performance through efforts such as cause-related marketing and more aligned business practices.^1–3,7

However, in the 1990s, the CSR scope transitioned to become more international mainly in response to negative publicity.^3,4 Meanwhile, the concept of sustainability which describes the ability to maintain various systems and processes – environmentally, socially, and economically – over time has also started to emerge.⁸ Then in the 2000s, CSR has become increasingly strategic and a larger concept. Moreover, public pressure to tackle corporate social, economic, and environmental issues led to the evolution of CSR practices, such as ethical labor implementation, philanthropy, environmental efforts and volunteering for instance.^1–3,7

Currently, CSR is a more global concept that became an essential part of business in both theory and practice as much as it applies to various fields. In fact, CSR brings a growing range of social obligations for the business organizations and has an enormous potential for strengthening society.

Sustainability

Corporate sustainability consists of adopting a strategy that enables companies to achieve a balance between the environmental, economic, humanistic and social aspects. Therefore, it produces value by achieving corporate performance in the long term and should be an important part of firms’ actions and philosophy. Rationalizing the consumption of energy, water or reducing waste production for instance can lead to optimizing resources and decreasing the costs. Furthermore, companies that are recognized as practicing sustainability and CSR can open up to new markets create more value for their stakeholders, and recruit more talented employees.^7,8 From this point of view, CSR might be considered as an element contributing to sustainability.

Thus, sustainability is a responsible way to practice business but also to make sure that the firm has sufficient natural resources to use and to prosper in the future. It also includes the monitoring of the supply chain’s members environmental and social impacts, fair treatment of the employees to enhance their well-being, and therefore their productivity and improving the corporation reputation.⁷

How Do CSR, Sustainability and Ethics Apply to Hospitals?

Hospitals, even non-private ones could be considered as a good example of corporations, as they offer care services and face many challenges regarding the way they provide these services in terms of quality and ethics. They, therefore, should be socially responsible.

Recently, the fore-mentioned concepts of social responsibility and sustainability have been considered and applied in the context of healthcare delivery suggesting a new model in hospital management, in order to improve their thorough performance⁶ (Figure 1).

Figure 1 Sustainable development. Notes: Reprinted from Wikimedia Commons, Johann Dréo; translation: Pro bug catcher/CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/. The original uploader was Calmos at French Wikipedia. / CC BY-SA (http://creativecommons.org/licenses/by-sa/3.0/)

Besides, these concepts can also have individual (To be adopted by each leader and employee of the hospital), global and systemic impact on the community and the society. Here is how these concepts can be relevant in the context of healthcare, with sustainability being the overriding principle in this new paradigm:^9,

In fact, sustainability in the context of healthcare organizations encompasses:

Social Responsibility

• Quality and relevance of care: providing the best care possible according to current scientific advances
• Accessibility of care (cost, waiting time to access consultation or hospitalization)
• Compliance to the law: regulations, taxes, labour law for the employees
• Community support: raising awareness about diseases and spreading the word about prevention methods among the community
• Creating jobs

Ethics

• Providing care regardless of the patients’ ability to pay
• Equity of care
• Protecting patients’ data and privacy

Environment

• Hospital’s impact on the environment:

• Safety: to work on providing a safe environment and protect employees and patients from accidents

• Managing wastes with respect to the environment
• Rational Water use
• Rational energy use considering other energy sources such as solar energy for example
• Transparency of the practices
• Supply chain: materials and equipment procurement from pharmaceutical firms known for the quality of their products that respect the environment, the labor law, and human rights.

Economy

• Adopting technological innovations that both meet the required quality of care and help reduce the expenses
• Reducing costs due to preventable and chronic conditions
• Supporting the workforce needs
• Rationalizing expenses (ie minimizing single use reprocessing devices)
• Boosting local economy by considering local products in the hospital supply chain

Healthcare organizations’ managers’ adherence to sustainability concepts are crucial to enable their implementation. Moreover, all hospital workers can also have a role to play, at various levels, according to their fields of action, as these concepts also refer to Bioethics principles, which are a combination of bioscience with humanistic knowledge, that have played a pivotal role in influencing policy changes in the last decades.^6–10 They can adopt them, spread the word about their importance, find allies who believe in the same cause and who also have the will to see them implemented in the hospital. However, it is important to mention that these actions need strong leadership, patience and perseverance, as they require cultural changes to be established.

Furthermore, they might lead sometimes to some delicate and conflicting situations. Here is, for instance, an illustration of one of the painful problems to which a healthcare organization could be confronted, especially in public hospitals in limited resources countries:

Making decisions about whether to treat a minority of patients who present a rare disease that requires very expensive therapies or to treat the majority of patients who present common diseases with an available low price treatment.

We are aware that such a decision should not be made on the hospital level, but it requires a national decision and prioritization process based on agreed-on, transparent, and fair procedures.

Nonetheless, this is the kind of dilemma that might occur and lead to big conflicts between managers and doctors or among doctors themselves in hospitals that have limited budgets. Needless to say that this situation can be very harmful to both the patients whose survival depends on the treatment and the doctors who feel frustrated, guilty and demotivated. Moreover, it alters the image and reputation of healthcare organizations that can loose credibility in the community they serve.

While assessing this issue ethically, it is obvious that each life matters and each patient has the right to be treated, given a chance to live and benefit of a good quality of life. So, it seems self-evident that doctors should struggle to convince hospital managers to pay for the needed drugs instead of comparing patients’ eligibility to treatment that is unethical and contrary to human rights. However, such an ethics-focused vision often leads to serious conflicts. Whereas, when the situation is tackled from a broader angle, integrating concepts of sustainability, social responsibility and ethics, following a roadmap with objectives on both the short and long terms, results could be achieved gradually as this is a realistic dilemma, which cannot be solved easily, and calls for the co-design of clear processes under multi-stakeholder participation. Accordingly, here is a proposition of some steps to follow:

• To raise awareness about the problem among the stakeholders: doctors, pharmacists, hospital managers, patient organizations, politicians, industry associations.
• Try to get multi-stakeholder adherence to the cause to have a bigger number of allies.
• Suggest to communicate in local or regional congresses and workshops conferences about sustainability, responsibility and ethics and invite experts to discuss these concepts with concrete examples.
• To include sustainability, responsibility and ethics in the curriculum in continuous medical education for doctors and other hospital workers.
• Doctors who believe in CSR should target leading roles in the institution and try to integrate decision-making positions such as hospital administration councils, for example, in order to be audible and bring to the table the issues related to CSR and try to propose solutions.
• To convince hospital’ managers to raise funds for rare diseases’ treatment and increase hospital budget, and plead afterwards for increasing health budget on a larger level.
• Include the civil society through the creation of associations that could support scientific societies in pleading for raising funds for these diseases.
• Integrate other hospitals and other doctors on a larger level in the discussion and make them allies and supporters of the cause.
• Try to bring the discussion to higher levels and plead for raising the country’s expenditure in health and hospitals’ budget.
• Once convinced and sensitized to the problem, decision–makers should strive to develop clear purchasing mechanisms, which prioritize sustainability criteria (quality, local economy, environment, access, etc.) in order to make the most sustainable purchasing decision.


Thus, trying to find a solution for a group of patient’s problem can improve the whole health system if the right tools of communication including all the components and stakeholders are adopted. It sure needs time, energy, commitment and passion but it remains possible if based on a clear and reasonable strategy combining the main principles of sustainability, responsibility and ethics.

In addition, with a clear roadmap, these reflections can lead to concrete actions as this topic is gaining more attention in the recent years, and discussed at the international level. For instance, the 11th Global Summit of National Ethics/Bioethics Committees, held in Berlin, in 2016, aiming to strengthen linkages between bioethics committees and policy-makers (ministries of health, education, science and technology), issued recommendations to the world health organization (WHO) about fostering bioethics principles within health sciences’ curricula and beyond as well as building the capacities of healthcare providers in medical and research ethics. Moreover, there were recommendations to Member States as well regarding the improvement of national capacity in bioethics and its implementation, as well as developing policies and regulations to address the main ethical issues.¹¹