Abstract
Planned Parenthood is a major healthcare provider and a nonprofit organization that faces multiple ethical issues. Most of them are related to the ethical challenges common for healthcare institutions, which means that they can be framed with the help of medical ethics principles. As a result, Planned Parenthood has developed a comprehensive program intended to maintain ethical conduct. Its key issue is the lack of a similarly detailed section on the revision of this program. In this paper, the need for such a section is explained with references to the ethical concerns and social justice issues relevant to the organization.
Introduction
Planned Parenthood (PP) is established in the United States (US) as a non-profit organization that focuses on reproductive health. PP has been working with the population of the US for over a century with a focus on underserved and rural areas; it is reported to provide relevant services to about 2.5 million patients (both male and female) a year (Lawrence & Ness, 2017). Its mission and vision are defined by offering reproductive health options, which include access to contraception, sex education, and abortion but are not limited by them (Planned Parenthood of New York City, 2019). Indeed, tests for sexually transmitted diseases and diseases that affect reproductive organs and breasts are some of the services that are most commonly provided by PP (Lawrence & Ness, 2017). PP is central to the health of women and men in the US.
One of the primary features that are significant about PP is that it is a medical organization (Planned Parenthood of the North Country New York [PPNCNY], n.d.). PP is tax-exempt and receives certain funding from the government, as well as donations from various sources (Planned Parenthood of New York City [PPNYC], (2014). It does state that the majority of its finance comes from health insurances (Burke, 2015), but the other sources of funding are similarly important, especially for understanding the ethical concerns that PP faces.
Due to the multiple controversies surrounding PP (Han, Han, Darney, & Rodriguez, 2017), as well as its immense importance as the primary provider of sexual health services in the US (Stevenson, Flores-Vazquez, Allgeyer, Schenkkan, & Potter, 2016), PP has become the focus of multiple research studies. Consequently, there exists enough evidence for it to be considered in the present paper. This investigation is dedicated to the ethical issues and solutions of PP. To narrow down the area of research, it will focus on the solutions proposed by the Planned Parenthood of North Country New York and Planned Parenthood of New York City [PPNYC] (2017) because the two provide detailed information about their ethics-related strategies.
This paper will offer a consideration of the key ethical theories that can be used to frame PP’s ethical issues and summarize said issues and PP’s approach to resolving them. PP’s strategies will be evaluated using relevant literature, and recommendations for improvement will be proposed with a consideration of factors that can affect their implementation. Most of PP’s ethical concerns and conflicts of interest are connected to its function as a healthcare provider, which necessitates the protection of patient rights and also makes it crucial for PP to maintain ethical conduct and avoid harming its patients. The administration of PP is, therefore, required to design the mechanisms that would enable PP to function ethically.
Philosophical Theories and Ethical Issues
The definition of ethical issues, as well as their solutions, can vary depending on the philosophical approach to them. As pointed out by Cooper (2012), there are two primary methods of conceptualizing ethical dilemmas: deontology and teleology. As defined by the author, the former refers to principle-determined ethics, in which the adherence to particular principles is considered necessary for ethical conduct. The latter presupposes considering the consequences of an action to determine if it is ethically appropriate. Cooper (2012) notes that it is logical to employ both approaches depending on the issues that are related to a particular dilemma, and the present paper will contextualize the ethical dilemmas of PP using this method.
As a medical institution, PP should take into account the concept of medical ethics. Traditionally, it is described as having several key principles, which would classify this system as deontological. The principles are those of non-maleficence (in other words, avoiding the causing of harm) and beneficence (producing positive effects) (Jakubowski et al., 2017). Furthermore, the principle of autonomy implies the importance of recognizing, respecting, and fostering the autonomy of patients, and the principle of justice covers a number of topics related to just, equal treatment of patients (Jakubowski et al., 2017; Mandal, Ponnambath, & Parija, 2016). Depending on the institution or country, other principles might also be present, but these are the most common ones (Jakubowski et al., 2017). The concept of medical ethics will also be used to explain the concerns that may be encountered by PP’s staff.
Ethical Challenges and Conflicts of Responsibility
For many people, the primary ethical controversy surrounding PP is that related to abortion; also, the people who oppose contraception may indicate similar discontent. While the fact that PP is a medical instruction is going to be acknowledged since it affects the ethical dilemmas encountered by its employees, the topic of the ethical nature of abortion and contraception is not going to be considered in this paper. According to the current United States legislation (Planned Parenthood v. Casey, 1992; Roe v. Wade, 1973), as well as the statements of international organizations like the United Nations or World Health Organization (UN News, 2018), access to abortion and contraception should be considered a significant aspect of human rights. The reason for that, as pointed out by the United Nations or World Health Organization experts, is the significance of supporting women’s reproductive freedoms, the negative consequences of making abortion illegal, and the ineffective access to contraception all over the world (UN News, 2018). The present paper will not dwell on the topic anymore and focus on the various aspects of the administrative ethics of PP.
Medical Service Issues
PPNCNY (n.d.) offers medical services, which means that it is subject to the laws and regulations that establish the ethics of medical procedures. This factor also means that PPNCNY (n.d.) might work with confidential and private information, which means that the medical details of the patient require appropriate safeguards. It is especially true since PP works with reproductive health. There are multiple aspects of sexual life that are sensitive, including, for example, sexually transmitted diseases, which are typically stigmatized (Calabrese et al., 2018). In general, PPNCNY (n.d.) highlights the importance of following the Patients’ Bill of Rights, which incorporates major ethical requirements, including confidentiality.
PPNCNY (n.d.) further acknowledges that conflicts of interest could occur in situations that are connected to the specifics of its services. Examples include favoring particular suppliers of customers, obtaining payments and services or gifts from various suppliers or customers, and abusing one’s power as a medical specialist to receive any benefits. PPNCNY (n.d.) also recognizes that PPNCNY (n.d.) employees may be in a position to influence a person’s actions, including those related to abortion but not limited to them.
Finally, due to the specifics of PP’s services, PPNYC (2014) employees might be in a situation when a sexually assaulted or exploited person requires help but does not want to report the crime. The conflict of responsibilities in this case (between confidentiality and reporting a crime) is easily resolved if the victim is underage: child abuse must be reported. All the mentioned ethical concerns reflect the medical principles of nonmaleficence and autonomy from the deontological perspective, as well as the consideration of potentially negative outcomes from the perspective of teleology.
Miscellaneous
Some other specifics of PP may also become a source of ethical challenges. As an organization that is funded by the government and donations, PP needs to be very transparent. It is especially true because of the ongoing allegations about the misuse of government funds (Burke, 2015). Furthermore, PPNYC (2014) states that the population which it serves and hires is rather diverse. As a result, nondifferential treatment and the prevention of discrimination at the workplace and with the patients is of utmost importance. These challenges are predominantly concerned with donor rights and justice. Justice one of the medical ethics principles and can be considered a deontological requirement for ethical conduct.
PP’s Strategies for Maintaining Responsible Conduct
Corporate Compliance Program
PPNCNY (n.d.) has introduced multiple safeguards for maintaining responsible conduct, which incorporate the reactions to external controls and a variety of internal controls. The former group incorporates various legislations and regulations, and the latter contains the standards of conduct, code of professional conduct, and code of ethics. All these controls are united through the Corporate Compliance Program (PPNYC, 2014). The Program exists to prevent, detect, and respond to unethical conduct and illegal actions of PP’s employees.
PPNCNY (n.d.) has a Corporate Compliance Officer who is involved in resolving the issues related to the employees’ noncompliance with the mentioned documents; the Officer can be considered the head of the Corporate Compliance Program. All the prevention strategies and mechanisms that are described below are a part of the Program. For a medical organization, the decision to implement a very specific and detailed ethics promotion material is a reasonable precaution.
Preventing Conflicts of Interest
The code of conduct includes the consideration of all the above-presented topics, including the problem of conflicts of interest. First, PPNCNY (n.d.) demands that its employees avoid creating the situations in which a conflict of interest could potentially occur. Among other things, they are discouraged from accepting gifts, attempting to abuse their position, and influencing another person’s decision. In order to reduce the possibility of the conflict of interests with respect to financial management, PPNYC (2014) has a separate Action Fund which is supposed to be independent. All PP resources are to be used either for PP services or charity (PPNYC, 2014). PPNCNY (n.d.) has also introduced a procedure that is meant to evaluate the financial relationships of itself and its individual employees with other entities.
Transparency Efforts
In order to achieve transparency, PPNYC (2017) presents relevant financial reports that detail its income and the ways it is used. PPNYC (2014) highlights the importance of ensuring that all the donation money is directed toward the purposes that were chosen by the government and donors. For example, it is established that PP does not use governmental money for abortion services, which is also illegal (Burke, 2015). Fundraising in PPNCNY (n.d.) is performed in accordance with the law; also, PPNCNY (n.d.) takes into account the code of ethics presented by the Association of Fundraising Professionals.
Miscellaneous Concerns and Related Strategies
PPNCNY (n.d.) takes into account all the legal regulations that are applicable to it, including those related to healthcare services. Furthermore, in order for their care to remain culturally competent, PPNYC (2014) uses national standards on the matter and offers interpretation and translation services to patients. PPNCNY (n.d.) also comments on its hiring policies, which are designed to ensure the high ethical standards of new employees. In particular, PPNCNY (n.d.) does not employ people who were convicted of a crime. Thus, more or less every concern presented above is addressed by PPNYC (2014) through a variety of strategies.
Training and Education
PPNCNY (n.d.) offers training and education that is meant to provide employees with all the necessary information about the legal and ethical requirements that they need to follow. PPNCNY (n.d.) establishes that not all employees are meant to participate in ongoing training activities, but everybody takes part in an orientation program. Furthermore, PPNCNY (n.d.) uses training and education to inform its employees about updates and changes in the law and other regulations.
Monitoring
PPNCNY (n.d.) has instituted audits that are meant to ensure the monitoring of the conduct of employees, as well as the quality of provided services. The audits are carried out by the Corporate Compliance Officer in cooperation with other administrators. PPNYC (2014) instructs all its employees to cooperate with audits that are launched by the government. Thus, PP recognizes the importance of reviewing the performance of its employees to ensure responsible conduct.
Whistleblowing
PPNCNY (n.d.) has a complaint filing and whistleblowing policy, which enables employees to report issues that they think might be associated with unethical or illegal conduct. While the primary two options for whistleblowing are concerned with contacting either a supervisor or the Chief Compliance Officer, and anonymous complaint filing is also possible. PPNYC (2014) comments that this option requires especially detailed reports, but it is an important alternative because it allows employees to remain anonymous if the fear of retribution keeps them from speaking up. PPNYC (2014) also notes that employees are not always notified about the changes that are initiated in response to their whistleblowing to protect their confidentiality.
Recommendations
The investigation of PP’s efforts aimed at ensuring the ethical conduct of its employees shows that the organization has a well-developed system of solutions which should prevent issues or contain and control them if they arise. In general, it is reasonable to implement a comprehensive system of documents that would enable ethical conduct when so many ethical challenges are present. However, some suggestions could be offered in response to the data provided by PP and relevant literature.
While the Corporate Compliance Program that was prepared for the North Country New York appears very comprehensive, it does not seem to incorporate a mechanism for review and improvement. It does mention that regular review of relevant materials is required without explaining how or when such a review should occur (PPNCNY, n.d., p. 1). Another reference to revising materials in the same document specifies that such revisions should be carried out “from time to time” (PPNCNY, n.d., p. 4). The manual does name the party responsible for the revision (Corporate Compliance Officer) and instructs them to consult other PP administrators, but this instruction is not very detailed.
The manual also references a fundraising code that is dated 1999 (PPNCNY, n.d.). It is probable that this code is fully suitable for the intended purpose, but the fact that it has not been amended since the beginning of the century could be potentially problematic. Furthermore, the Code of Conduct of PP that is meant for its New York subdivision is slightly over five years old (PPNYC, 2014). Thus, PP seems to recognize the need for revising the documents, but the instructions for achieving that outcome are not very detailed. Some rather outdated policies are also present, and while it is possible that the recent revisions showed that no improvements were necessary, this practice can appear concerning. The problem is that outdated policies which do not reflect the current state of events may be insufficient for the management of the above-described ethical issues.
Therefore, the primary recommendation for PP would be to establish a detailed instruction on how to carry out the revisions of the Program. Research on the topic highlights the importance of the timely revisions of ethics-related documents, especially in healthcare organizations (Epstein & Turner, 2015; Komić, Marušić, & Marušić, 2015). It would be reasonable to institute regular revisions, but ethical codes also need to be updated after particular events, which can include misconduct or the changes in legislation.
As noted by PPNYC (2014), its training gets updated in response to changes in regulations, and the same should apply for any other element of the Compliance Program. Furthermore, it is necessary to specify the people responsible for the revisions and involved in it; the procedures and documents that would be employed in the process need to be developed and implemented. Thus, PP needs a specific, detailed mechanism for the continuous updating and improvement of its Corporate Compliance Program.
Possibility of Guerilla Movements
PP has prepared the ground for potential guerilla movements. In particular, there is a mechanism for whistleblowing, which allows avoiding the need to report an issue to a specific supervisor; filing it anonymously is possible instead. Given that guerilla consists of finding the means of undermining the authority that has delegitimized itself due to unethical conduct, this method may be working (O’Leary, 2014). However, it can be reasoned that PP guerilla movements would most likely be internal.
Indeed, PP has been consistently attacked by anti-abortionists, and it faces continuous funding cuts and increased scrutiny from the government (Han et al., 2017; Hillard, 2017; Lawrence & Ness, 2017; Rubin, 2018). Certain states have already limited PP’s operations rather severely, including Texas, and a recent study finds that the outcomes of this decision are predominantly negative with women’s reproductive health options, especially access to contraceptives, shrinking dramatically (Stevenson et al., 2016). This factor may make PP employees less likely to want to report issues to outsiders or leak information about misconduct since PP may suffer major problems as a result of a scandal. Therefore, certain forms of guerilla movement are unlikely to arise because they would harm the organization too much.
However, in light of the proposed solution, internal guerilla movements may be quite helpful and sufficient. From the perspective of revising existing documents, internal dissent and discontent, even if it is not allowed to express it openly, is among the factors that can foster change. Given that PPNYC (2014) emphasizes the possibility of anonymous reporting and highlights its dedication to protecting whistleblowers, this path of resistance should work for PP and promote the improvements of its Corporate Compliance Program.
Factors Affecting the Implementation of the Recommendations
Multiple factors might affect the implementation of the proposed changes, and Cooper’s (2012) ethical decision-making model can help to identify them. First, for the change to take place, the administration of PP needs to acknowledge the presence of the problem, which consists of the ineffectual definitions of the processes and procedures related to the Program’s revision. This step will determine if the issue is addressed at all, which makes it very significant. Some of the factors that can bring forth this element of the change include guerilla movements, as well as the actions of individual administrators, who may attract the attention of PP’s management to this concern.
If the problem is determined, the solutions to it will be presented. It is not unlikely that the status quo will be defended since resistance to change is a common issue (Burnes, 2015). However, the actions of employees and administrators can help to divert the attention from this option and toward change. Guerilla movement can be helpful in this regard as well, especially if the status quo is supported by higher-level managers.
Following the rejection of the status quo solution, the desired version of the document which would detail the Program revision procedures will be negotiated. Most likely, the Corporate Compliance Officer will be required to supervise the process, but the involvement of multiple specialists would help to ensure the development of a well-adjusted document that would work for everybody involved. Given that PPNCNY (n.d ) instructs the Officer to cooperate with other administrators, the specifics of the corporate culture of PP probably support collective decisions.
Finally, when the option is determined, its implementation should take place, and the monitoring of PP’s adherence to it will be carried out. Given that PPNCNY’s (n.d) procedures seem to support the idea of adhering to codes of ethics and monitoring this process, the people who will be involved in this stage would be sufficiently familiar with the procedures. In summary, the primary factors of importance to the change would be the mechanisms of spotting the issue (including, for example, whistleblowing), PP’s existing structures and organizational culture, and individual reaction to change, including resistance to it.
Anticipated Outcomes
The targeted outcomes of the proposed recommendations consist of a better-functioning Compliance Program. In the long run, improved chances of preventing and detecting unethical conduct might come out of it, but essentially, the change targets the mechanisms through which PP’s administration works to prevent and manage misconduct. Given that it presupposes ongoing self-improvement of the Program, it is reasonable to assume that the primary outcome would be a better, more flexible set of ethics-related documents that would fit PP’s needs as they arise.
An organization is unlikely to be able to control all of its employees and administrators at all times. Codes of ethics do not imply immediate changes in behavior (Komić et al., 2015). As a result, the goal of eliminating misconduct is not proposed for PP, but it is suggested that PP will become better at handling it and using the lessons learned from it. At least some of the controversies associated with PP suggest that unethical or potentially unethical conduct does occur even in a non-profit that introduces multiple safeguards against it (Hillard, 2017; Rubin, 2018). However, such cases provide valuable information that can help to prevent future misconduct, and PP needs to use similar events as learning opportunities that might indicate certain weaknesses in its Corporate Compliance Program. To summarize, the proposed change institutes a mechanism for continuous self-enhancement within the organization’s ethics-related materials that will employ lessons learned from misconduct and other opportunities for improvement.
Social Justice and the Ethical Issues of PP: A Conclusion
PP’s specifics (particularly, its involvement in medical services) implies that social justice themes are going to be very important to it. In fact, PPNYC (2014) acknowledges it directly: the company comments on the significance of equality and human rights, especially reproductive rights. Almost every of the above-described ethical challenges is related to patient or donor rights. Furthermore, the justice element of medical ethics is very relevant: PPNYC (2014) notes the importance of non-preferential treatment of all its patients, which is a part of patients’ rights but is also connected to equality and justice in the social justice sense.
Reproductive rights, especially when women are concerned, are crucial for the achievement of equality. For women, unplanned pregnancies are a major health and social security risk (Lawrence & Ness, 2017). Furthermore, other services offered by PP are significant for the health of both men and women of the US. From this perspective, PP provides crucial services, which is why it is especially important that unethical conduct (for example, misallocation of funds or mistreatment of patients) is prevented and controlled. Given PP’s history of being targeted by anti-abortionists, unethical decisions can endanger PP’s ability to proceed to address the problems of underserved populations (Han et al., 2017; Hillard, 2017; Rubin, 2018; Lawrence & Ness, 2017). Thus, ethical conduct within PP is a major requirement, which justifies the extensive strategies already employed by PP and the promotion of their continuous improvement.
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