How do large organizations maintain ethical standards

Hospital misery, institutional pathologies, and clinical organizational ethics


Staff and patients in institutions of organized health care experience and express a variety of miserable conditions in these organizations. Some “misery” can be explained in the context of a theory of institutional pathologies as disruptive effects of the activities and structures of organizations in the political system (health policy) and the economic system (health economy). Therefore, Clinical Ethics Committees (CECs) cannot effectively counter such misery or even address them. Organizational ethics can address it, but it cannot counteract it effectively. It is proposed that organizational ethics be reinforced by a theory of institutional pathology. Institutional pathologically enlightened, "clinical" organizational ethics can help in ethical theory and practice, for example for members of KEKs and organizational ethics consultants, to considerably expand the possibilities of observation, evaluation and, if necessary, improvement of disturbed responsibility relationships.


Definition of the problem

Staff and patients in institutions of organized health care experience and express a variety of adverse conditions of these organizations. Within a theoretical framework of institutional pathology we can explain some of these “miserable conditions” as effects of the activities of organizations belonging to the political system (health policy) and to the economic system (health economy). Clinical ethics committees (CECs) cannot effectively handle such adversities or even address them properly. Standard organizational ethics can address them but cannot handle them effectively.


I propose to strengthen organizational ethics by a theory of institutional pathology. Basic nosological distinctions such as disease, illness and sickness, whose primary reference is to biological organisms and persons, can be analogically extended to socially constituted entities (e.g. hospitals) in terms of functional deficiency, miserable conditions, and need for reform of such entities. A very promising focus for analysis are organizational disorders of responsibility allocation. This group of institutional pathological disorders engenders, amongst other kinds of miserable conditions, specifically morally relevant miserable conditions.


The institutional pathology paradigm, oriented to concrete institutions and organizations, can help “clinical” organizational ethics to considerably expand, in theoretical ethics as well as in ethically guided practice e.g. for members of CECs and organizational ethics advisors, the capacities for observing, evaluating and, if necessary, amending disturbed relations of responsibility.

Why organizational ethics at all?

In every individual case of organized medical treatment, the ethical quality depends on much more than just the good will and ability of the people directly involved. James Evan Sabin, the director of the Harvard Pilgrim Health Care Ethics Program, sums it up: “The ethical quality of medical care depends as much on the ethics of organizations as the ethics of individuals. For better and worse, the culture and policies of hospitals, group practices, insurers, and other health system organizations shape individual clinician-patient relationships. We can't have ethical healthcare without ethical organizations! "(Sabin 2016, p. 111). The spread of this insight is in the background of a growing interest in the theory and practice of organizational ethics (OE), also in this country.Footnote 1

Institutional forms of ethics counseling and clinical ethics committees,Footnote 2 To which the organizational culture of the health care system has meanwhile become accustomed, their knowledge base, competencies and responsibilities are too limited for the complexity of organizational ethical problems. These arise on the lines of tension between more or less well-founded concerns of professional medical treatment, more or less well-founded economic concerns and more or less well-founded concerns of administration and management within an organization and in the relationships with the other organizations with which they are is functionally linked. More precisely: If miserable conditions in an organization become a problem, then those problem aspects emerge which organizational ethics in particular should be able to contribute to the solution as soon as the “moral costs” d. H. watch out for moral injustice that arises from friction between these diverse concerns. As soon as diverse (medical, nursing, economic and business management, administrative, political) ethical rationalitiesFootnote 3 critical ethical judgment must be at playFootnote 4 reckon with hierarchical conflicts between them and develop forms of morally integrity-based compromise and compensation. If organizational ethics wants to be proactive, it must also stimulate morally targeted organizational learning processes, develop appropriate reorganization proposals for this purpose and be able to analyze and criticize resistance to their implementation. These demanding tasks require a large tool kit to which the following considerations aim to add the tools of a theory of dysfunctional institutions. This attempt is new, can only be shown here in the floor plan and expects the reader to use a series of unfamiliar terms and figures of thought that break out of the familiar language games of organizational consulting and hospital management - but with the very practical long-term goal of finding your way back to them enriched.

Why organizational ethics at all?

With regard to hospitals and related facilities, the existence of which is ultimately justified by the general interest that people with health problems can obtain specialist help, we seem to have a simple normative prioritization principle: in order to make a moral assessment of the activities of hospital-type organizations, need standards clinical ethicsFootnote 5 the highest-ranking, because it is about facilities for sick treatment. But it is not that simple. The normative highest ranking is not already the normative whole. In hospitals with a high division of labor and other administratively complex health care facilities, persistent problems often arise out of misery, the moral aspects of which pose challenges to application-oriented ethics that neither the usual, even after 40 years nor a few prima facie principles (“Georgetown mantra “) Fixed bioethics (Beauchamp and Childress 2019), nor only the medical ethics fixed on the inner values ​​of the doctor-patient interaction.

The long list of such morally problematic misery includes: under-, over- and incorrect care of patients, exploitation, demotivation and discrimination of staff, ineffectiveness, inefficiency, corruption, misleading the public or authorities, dishonesty favoring remuneration procedures, wagon castle mentality and enemy images Nepotism, formation of clusters, egomania at the expense of organizational goals, confusion of personal and professional interpersonal relationships, reification of people (e.g. through stereotyping), denial of grievances, suppression of criticism, over-legalization, over-bureaucratisation, over-inflation, enrichment (cf. Kettner 2011).

Frictions between disparate concerns at the level of specific organization themselves (e.g. friction between administrative concerns of data protection and business concerns of economy in the privatized hospital XY) appear when looking at the level of action as difficulties in the various types Relationship and interaction forms of people, namely, those who make up the organization's staff and clientele. Their relationship and interaction forms are standardized in very different ways due to the wide variety of role definitions within the specific organization at different functional points. The concrete organization as a whole, however, is the unit that transforms and coordinates the forms of relationships and interaction of all people. Think of the relationships between and within professionalized professional groups, e.g. B. between medical and nursing staff, but also between hierarchical levels within the medical and nursing staff. Think of forms of learning and teaching relationships (e.g. training and further education for staff or students) or forms of relationships in medical research (e.g. teams of third-party funded research in university hospitals). In all formal organizations based on the division of labor (e.g. in commercial enterprises and administrations), contractual forms of relationship are highly important (Donaldson 2009). Because such relationships create and guarantee rights and obligations (e.g. rights of doctors and patients in employment and in treatment contracts; the rights and obligations of producers and consumers in free-market companies; the rights and obligations of superiors and their subordinates in bureaucratic institutions) .

Misery of the DRG transformation

Contractual relationships are particularly suitable for translating economic and political requirements, forces, standards (e.g. remuneration requirements, financial constraints, profitability standards) into the organizational interior of health care. Such specifications, forces, standards come e.g. B. in the macro-allocation decisions of health policy and the cost control policies of insurance carriers.

The conversion of clinical performance remuneration to a DRG system in Germany is a prime example of such translations. The DRG system was originally only a cost control system, but not a remuneration system, but in its form (G-DRG) introduced in Germany since 2003, it is endowed with this function by health policy. In interaction with a systematic under-fulfillment of the responsibility of the public sector to cover investment costs for hospitals, it leads to the financial misery of many non-privately owned hospitals. This creates a strong pressure to save, which the business management of these houses then has to deal with and - in the understanding of good business responsibility - can often only deal with it in such a way that the medically ethical priority of the medically understood patient well-being is impaired (working group "Economization" 2020).

Interactions between the functionally perverted (i.e. administrative concerns overloaded with business management concerns) DRG system, for which specific health policy organizations are responsible, with - also politically promoted for a long time - strong interests of market economy organizations in converting the health system to the health economy have a significant share in many of the troubled misery that those who suffer are increasingly complaining about (Stern 2019) and, of course, often all too sweeping, are criticized as the “economization of the health care system”.Footnote 6

Four conceptions of organizational ethics

How should OE be theoretically set up that could do justice to the complexity of inter- and intrasystemic problem-generating interactions, instead of identifying and assessing moral problems as they arise within a specific organization, at best only under the given functional conditions of this organization? In other words: How can OE be critical and reform-oriented?

At least four clearly different conceptions of OE have emerged so far (see Krobath 2010, p. 553): OE as (1) management ethics, as (2) mission statement ethics, as (3) ethics of specific individualized organizations, and OE as ( 4) Practice of “organizing ethics in organizations” (Krobath 2010, p. 556). In the handbook by Krobath and Heller, the fourth reading dominates, "the organization of ethical reflection as a process that has to be permanently renewed in organizations" (Krobath and Heller 2010, p. 19).Footnote 7

This fourth, practical intervention reading certainly has a lot to offer. Why? In short: To the extent that OE becomes normative, that is to say, beyond the improvement of factual knowledge, it also seeks justified (re) evaluations and (re) normalizations, it is a form of applied normative ethics. In its application, normative ethics is not a free-standing and contemplative, but a committed and transformative practice. The interventionist use of moral thought is a form of the exercise of discursive powerFootnote 8 and thus a practical relationship, not a merely theoretical one. Applied ethics intervenes as soon as one tries to assert normative convictions of a moral nature (e.g. moral principles from philosophically established positions such as utilitarianism, contractualism, Kantianism, "Principles of Biomedical Ethics" etc.) in certain areas of practice in order to address certain problem areas, which typically arise there and have a morally irritating side to be dealt with better, in a morally qualified sense of "better". The fact that the moral improvement of practices perceived as problematic is the core business of applied ethics makes those who practice it into a kind of second-order problem-affected. We make moral problems that people have in the practice in question virtually our moral problem, for example when we recommend certain changes with an organizational ethical mandate. So at least the theory This intervention practice tries to clear up the stubbornness of what they construct as “moral problems”. Because if the awareness of the problem is only inadequately clarified, the danger increases that problems that are not moral when viewed in the light of day are taken to be and treated as purely moral - the dangers of "moralism" - and vice versa problems that (at least on the part of the direct Affected) are understood as moral, not to be treated as such, but z. B. as purely technical, psychological, administrative, managerial, economic etc. - dangers of "moral repression". And of course, well-organized OU must also be organized in such a way that the scope of its reflective powers can still be given operational sustained attention, i.e. can achieve something if it does not just use the functions that are already in operation and processes that have already been set up, not just those locally affirms the existing institutionalization status of diverse ethosrationalities, but keeps a distance, interrupts processes (Heintel 2010, esp. p. 460) or irritates and thereby creates contradictions (Krainer 2010) and conflicts.

The third concept, OE understood as ethics applied to specific individualized organizations and types of organizations,Footnote 9 has an objective priority over the fourth or at least forms a necessary supplement. Because before one tries to introduce ethics (“ethical reflection”) into an organization, one has to explore how much responsiveness to moral irritation and what institutionalized ethosrationalities already exist in the organization concerned (e.g. in a privatized university clinic: a medical one Professional ethos, a nursing professional ethos, an entrepreneurial ethos, an academic ethos), which lines of conflict these different ethical rationalities create and how such lines of conflict change when the organization is plagued by conspicuous disturbances of responsibility that require explanation (e.g. as a result of excessive economization or commercializationFootnote 10).

Form and content of morality as an object of OE

A blatant weakness in the OE literature on all four types is the often abstract and formal talk of morality in empty references to “values”, “ideals”, “the moral point of view”. Whoever leaves the relation to morality undefined in terms of content, apparently gains an advantageous openness to the most diverse moral concepts. However: If the reference to morality is left indefinite in terms of content, it is no longer possible to state what turns a recognizably relevant problem into a recognizably morally relevant problem. Strange as it sounds, this leads to morally blind OE.

A structural analysis of responsibility that is open to interpretation offers a better theoretical and therefore also for OE better handling of moral diversity, the unity and diversity of known moral concepts. A corresponding perception of responsibility is indispensable for all morally qualifiable behavior. As necessary and sufficient for dealing with a problem with a moral problem, the normative conviction that someone (or something that counts for us as an object of consideration within morality) is counted.has a certain "moral status") happens through certain activities on the part of certain actors (these can be natural persons or corporate actors) something wrong that shouldn't really be. The main distinction in concrete, generally widespread morality ("Common Morality", Gert 1998, 2007) is the adverbial distinction between wrong / not-wrong Behavior of actors who count as reason-responsive actors for us, d. H. as responsible and reasonable actors (cf. Kettner 2014). Of course, it is often the case that we do not immediately recognize something wrong that is actually not supposed to be, clearly and immediately, especially not in situations of organizationally mediated action, for example in a multi-professional treatment team within a functionally highly differentiated organization. Subjective impressions of the questionable, feelings of discomfort, feelings of being hurt must first be articulated and clarified, diffuse attributions of responsibility must be explored, problem definitions must be sorted, etc. B. by clinical ethics committees (cf. Kettner 2008).

The concrete, generally widespread morality by no means only contains those strong normative evaluation reasons, the meaning of which we can also express as generally binding moral rules (e.g. “neminem laede!”, “Do not cheat anyone!”, “Fulfill your obligations!”, “Keep your promises ! ”Etc.). Rather, our morality forms a rich normative network of diverse reasons. One can make it clear to oneself: The recognition worthiness of every certain generally binding rule with a moral exclamation mark, so to speak, always has its convincing “background” for us, which substantiates the validity of the rule and justifies its authority from our point of view. Philosophical ethics has developed a number of strong background positions (including utilitarianism, contractualism, "Kantianism"). But just as important in concrete, generally widespread morality is another kind of good reason, which we could call "reasons for debt relief": For example, we would deviate from a certain moral rule in a concrete situation (e.g. deviating from the generally firmly established rule The medical truthfulness in special situations carefully and carefully informed information) only then condemn it as morally wrong if in the concrete situation, well understood, there are no good reasons which, if all those concerned could and would only appreciate it impartially, the breach of the rule in the concrete case as free let understand of what is wrong that should not be. For example, in an acute situation where there is a shortage of necessary treatment materials without remedial measures, the planned failure to care for some seriously injured people who have the lowest chance of survival and care for others who have better chances of survival would be a massive moral injustice from a professional ethical point of view if we had not learned also to adequately appreciate the good reasons for debt relief in this situation. The keyword triage stands for a morally important learning process.

From countless examples of our life experience, which range from the dramatic to the most banal, it becomes clear: Moral normativity ("our morality"), culturally embodied in the informal network of (1) generally recognized moral rules, (2) authoritative backgrounds and (3) convincing reasons for excuse, is not a rigid, but an adaptive system of orientation that intelligently adapts to the changing circumstances of our everyday life. OE always works, admittedly in different ways depending on the conception, with what can and should become of this orientation system under the modifying forces of the "reality of life" of a specific organization.

Responsibilities as an appropriate moral perspective for OE

Miserable organizational states become specifically morally relevant to the extent that changes in the respective states simultaneously make changes in the balance sheet of unexcused violations of moral rules that are worthy of recognition. In other words: To the extent that miserable organizational conditions actually lead to an injustice that should not and should not be, or make its occurrence considerably more likely. OE is effective as an advocate of moral problems and problem solving only if it is through its interventions these The balance sheet demonstrably improved, and not (only) the company balance sheet or the average patient satisfaction. This is how Sabin sees it (2016, p. 115, emphasis mine, M. K.): “The ultimate aim and justification for organizational ethics activities is to make an ethically meaningful difference in how an organization functions. Unless that happens, the activity will be merely academic, and likely to lead to frustration. The effort to make a difference requires managerial skill on the part of the clinical ethics committee, strong relationships with organizational leaders, and practical understanding of what kinds of outputs will be valued and used by the organization. "

The moral convictions of some coincide sometimes more and sometimes less with those of the other. Moral diversity can be dramatic, especially in patient treatment situations. What would be a life-saving blood infusion in the light of a professional medical ethosrationality, the omission of which would be morally massively wrong, may turn out to be a highly disastrous moral injustice in the light of another ethosrationality (e.g. one based on religion). Such divergences arise from the embedding of our concrete, generally widespread morality in different ethical rationalities and are by no means incompatible with their claim to generally binding force. However, divergences make it clear that there is considerable scope for modulating the rules and ideals of general morality within the framework of different ethical rationalities. Sensible ethics, ergo also sensible OE, must do justice to such leeway. It is of little use to fixate oneself on a certain doctrine of justification at the end of the justification of the rules of general morality, if at the intellectual level of philosophical doctrines of justification itself no monopoly can ultimately be rationalized out after all.Footnote 11 From this assessment, an insight that is helpful for the theoretical construction of OE can be gained:

“The moral perspective” in ethics, i.e. also in OE, is only understood sufficiently openly when it does not mean more or less than a skill that is typically and normally developed in the communication and interaction community of people: The ability to (1) take representative seriously, such as (2) intentionally controllable activities (3) in certain areas for which certain actors are considered responsible, (4) for better or worse (5) all of the people (and possibly also animals and other "moral objects"), which should count for us in this regard - all this always interpreted in the light of the relevant ethical rationalities. For the sake of simplicity, we can describe the complex ability structured in this way as Affected refer to and mean the ability to interpret responsibility in a moral-normative way and to exercise it in practice. Almost everyone can do this, many corporate actors, e.g. B. Organizations with adaptive management structures can do it too (cf. Neuhäuser 2011).

On the approach of a theory of institutional pathologies

In the remainder of this essay I would like to underpin the following suggestion: As an ethic applied to specific individual organizations and types of organizations, OE should include diagnosis, explanation and amelioration of disorders in organizations on its agenda, with priority on those disorders that impair the perception of responsibility Systematically and negatively affect the type, whereby the reasons for the emergence or perpetuation of the disturbance lie in the "life" of the organizations themselves and not, or at least not solely, in the personal lifestyle of the people who make up their staff and their clientele. If we want to take the concept of disorder seriously, an extension of OE by a theory of social, more precisely: institutional, pathologies appears to be indicated. The good sense of such a theory would be to transfer the refinement of the disease and disorder thinking developed in medicine and psychology in a factual and insightful way to active, organized social structures and to make this usable for OE, not least to realistically (er) expect success from intervening OE. to be able to estimate. Certainly, one is well advised to look for the opportunities for desirable morally relevant processes of learning and relearning in the “organizational culture”. But what OE would like to achieve with certain interventions, food for thought, change processes, etc., and possibly do, will depend not least on how and to what extent the organization and its “culture” are disturbed. Appropriate knowledge would make OE more prudent and in this respect: improve it.

If this envisaged expansion of the agenda of specific OU has to have its own name, “clinical OU” might be an appropriate term, because it is about diagnosis, explanation and improvement of disorders, albeit by organizations.Footnote 12 This change of perspective is amazing, but not a bluff. A growing research literature deals with dysfunctional organizations, especially business enterprises.Footnote 13 The topic of “social pathologies” is also gaining increasing attention in discourses on social philosophy and social psychology.Footnote 14 The question of how we can theoretically understand severely disturbed social structures is not only scientifically relevant, but also of great practical and political interest, since the theoretical diagnosis of disorders inevitably leads to the practical question of how they can be remedied.

As "institutional" pathologies we would like to refer to pathologies whose genesis (etiology) and possibly also the way they appear (symptoms) are not to be found in the biotic and mental processes of natural persons and other living beings, but in the functionally arranged socio-cultural processes and their Products, the meaningful practices that make up active organized social structures. The three main nosological categories of objectifiable disease (disease), the painfully experienced impairment (illness) and the need for treatment (sickness) we propose the categories of functional deficiency, misery and need for reform as socio-theoretical equivalents (cf. Jacobs and Kettner 2016).

Explanation: The general term "misery" may sound strange, but it is good, because regardless of whether one thinks of economic, business, financial, political, moral, etc. misery, an unhappy and, in a specific way, miserable condition is always meant. The somewhat awkward-looking term “functional deficiency” refers in both German and English specialist terminology (cf. functional deficiency) on faulty, failing or failing, poorly or fault-prone running, deficient in their "required" performance, in their effects unfavorably deviating from their "normal" target values ​​or inadequately coordinated processes within the overall activity of a unit that integrates and, as a whole, is embedded in a fellow and environment, is organized in a self-sustaining manner (as in natural organisms) or should be (as in technically or socially designed artefacts, e.g. organizations).Footnote 15

In order that productive borrowings from psychological and medical disease and disorder theories become relevant and not get stuck in the metaphorical, causally relevant mechanisms must be identified: First, those that cause certain functional deficiencies in the relevant active social structures, maintain or make them resistant to change. (With a view to the example of the DRG misery outlined at the beginning, one of these mechanisms would be the coupling of the function of providing therapy according to medical indications with entrepreneurial functions by means of a health policy causal chain). Second, there are causally relevant mechanisms that first of all turn functional deficiencies into misery, misery of the social structures concerned themselves (in clinics e.g. miserable organizational conditions such as excessive employee dissatisfaction and staff turnover) or misery in other social structures that are functionally linked to one another.

For modeling institutional pathologies

The approach to institutional pathologies allows the conceptual modeling of different forms of disorder. This can only be indicated schematically here.

The basic biomedical model is tailored to individual organisms. This is where the etiology, symptoms and therapy find their ontological place. In a first, simple disorder model of institutional pathology - let's call it M1 - we now expand the etiological location and the therapeutic location, but not yet the symptomatic location. A classic example of M1 was Freud's diagnosis that bourgeois sexual morality caused massive amounts of neurotic disorders. Nota bene: As early as 1900 some doctors (e.g. Alfred Grotjahn) were talking about “social pathology” in order to take a new approach, namely aetiologically expanded approach, of already well-known diseases such as B. To describe tuberculosis from a "social point of view". The aetiological site was expanded to include “pathogenic” social conditions (e.g. unsanitary working and living conditions, or, as with Freud, an over-repressive, institutionalized sexual morality). The logic of institutional pathological and medical diagnoses does not yet diverge in the M1 model: the disease / disorder manifests itself in people. However, M1 already offers a good starting point for research on institutional pathology. This becomes clear as soon as we allow more modern social-theoretical constructs for those “social conditions” which, according to the M1 model, receive an etiological local law because they are understood in M1 as pathogenic (pathogenic) B. Mentalities, dispositives, discourses, narratives, strategies of exclusion, structural relationships of violence, social inequality and others. m.

A model that is enriched compared to M1, let's call it M1 +, results when it is possible to pinpoint new, surprising fault diagnoses and / or new painful impairments that are in the Disease-Catalogue of medically recognized diseases and painful impairments of people do not (yet) occur, so lege artis does not yet "count" as diseases and disease symptoms (e.g. self-alienation, enhancement addiction, device dependency, climate catastrophe depression, or with View of severe distortions in the formation of public opinion in times of Covid-19 and Corona control policy, possibly massive infosphere disorder as a novel functional deficiency in the media system).

Really interesting possibilities for expansion arise when we have active social structures as such to make the reference of illness and disorder judgments: Model M2. In pathologically disturbed active social structures, important internal and external functions work deficiently, in such a way that this manifests itself as a misery in all or in some of the normal services of the social structures concerned that are rightly expected. Active organized social structures can even be quasi terminally ill - the dissolution (e.g. the dissolution of a hopelessly corrupt clinic) would then be an equivalent for the exitus.

Since one should speak of illness / disorder anyway only in the case of massive, at least non-trivial disorders, the following would be a clear case of massive functional deficiency: social structures are normally open to innovative or reparative redesign and new constructions, to reforms and corresponding learning processes, if only enough people are involved in the activities of the entities concerned (ie their staff and clientele, e.g. students, lecturers, administrators as staff of the university organization), find these activities “no longer in order” on a massive scale. Assuming, however, that certain functions were so severely disrupted that no remedial action could be found with the available “on-board resources”, then we would have a clear case of more massive Deficiency. And if the functional deficiency were so massive that a reform would no longer be feasible by other means, we would be from one hopeless case speak. If the social structures concerned were dissolved, we could certainly move away from the socio-cultural death speak. Organizations can die from the complications of their systemic diseases.

We also find a socio-pathological equivalent of Illness, So of disease value, painful impairment? Social structures certainly do not suffer like humans and animals, but why should it be impossible, with the help of appropriate value theories tailored to the peculiarities of the respective structures, certain miserable conditions that arise from certain functional deficiencies, as painful impairments, so to speak the affected social structures to understand? We can speak of the misery of the social structures themselves (instead of just the illness-related suffering of sick people, for example parts of the staff or clientele of an organization).

In contrast to M1 and M1 +, in M2 the logic of socio-pathological diagnoses and the logic of medical diagnoses really diverge, because according to M2 social structures can and Living beings be sick or healthy, and this also independently of one another. There can be healthy, thriving social structures with healthy staff. There can be sick social structures with sick staff. There can be sick social structures with healthy staff and those that flourish, although or even because they operate with disturbed or sick staff. In addition, the models M1 and M2 can be combined with one another: If the extent of the misery of a social entity S that is sick according to model M2 also includes effects that count as pathogenic effects according to model M1 (= effects that significantly increase the probability of certain groups of people, incurring health problems), then we have the case that pathologically disturbed social structures directly or indirectly make people sick, i.e. H. sick in the usual medical sense.

Model M2 can also be enriched: In model M2 + it should be made understandable that functional deficiencies in S do not appear as misery in S itself, but in such a way that S becomes pathogenic for other social structures S ′, which in turn only become functionally deficient through S ( "Sick") and get into miserable conditions. (A clear case of M2 + would be a police agency infiltrated by a successful mafia organization.)Footnote 16.

Pathologically Dysfunctional Responsibilities: An Outlook

How can we identify responsibility disorders in clinics and related facilities for organized patient treatment, how can we explain the emergence of such disorders and the scope for their changeability from an institutional pathological perspective? The models outlined in the previous section are certainly only the beginning of a research program. Conversely, disorder and disease models refer to concepts of health. Perhaps a concept of resilience that is rich in organizational ethics can play a role in the theory of institutional pathologies that is similar to that of health terms in medicine. We can also apply a concept of moral integrity that has been adapted to organizational ethics critically to organizations (Heubel and Kettner 2012). Furthermore, progress can be expected from the differentiated description of different disorders in the social pathology paradigm. So far, we only have a single, for OE central, disorder in view of the responsibilities. Because, as explained above in the section on responsibility as an appropriate moral perspective for OE, responsibility disorders form a group of disorders that can be explained by institutional pathology and that are particularly important for the OE of specific organizations and types of organization and should be dealt with. More precisely: disturbances of responsibility that contribute to the emergence, maintenance or persistence of morally significant misery.

Responsibility is a combined function of knowledge and agency; whoever knows nothing is as irresponsible as someone who is powerless. Our institution-pathological hypothesis says first of all that responsibility disorders arise from functional deficiencies in those processes that the Fit of power (in various forms) and of knowledge (in various forms) that have formed in the organizational history of a specific organization at its decision-making points.Footnote 17

Since the responsibilities of an organization, as stated, also depend on its ability to be affected, the organizational ethical hypothesis further states that responsibility disorders occur specifically from morally relevant Making misery more likely and not just, as would be expected from a business, legal and psychological point of view, an increase in the risk of insolvency, image damage, legal proceedings and high levels of staff dissatisfaction.

It would be a fruitful research perspective for the theory of institutional pathologies to use case analyzes of specific organizations to examine which of the many problems that plague them can be explained, assessed and possibly improved as misery arising from functional deficiencies. The gain for “clinical” OE would be better answers to the question under which conditions and by which causal mechanisms accountability disorders arise and translate into morally miserable organizational states.

One may object to the “clinical” conception of OE proposed here that it is too complicated and speculative and remains too far outside the horizon of the work of ethics committees and organizational consultants. I think, however, that the steep claim to bring together empirical organizational science and organizational ethics under the reference problem of diagnosis, explanation and treatment of disturbed institutions is worth the effort. It offers fascinating views. Prospects for an organizational ethic with bite.


  1. 1.

    For an overview of 30 years of largely Anglo-Saxon literature on organizational ethics in health care see Suhonen et al. (2011). Hall (2000) is still interesting as an attempt to bridge the gap between entrepreneurial ethosrationality and the ethosrationality of doctors. The manual by Krobath and Heller (2010) is representative of the predominantly German-language literature on organizational ethics in the health and business sectors.

  2. 2.

    For the dissemination of ethics advice in Germany see, for the tasks and dissemination of clinical ethics committees see Woellert (2019), Neitzke (2009), Frewer et al. (2008).

  3. 3.

    As "ethosrationalities" I refer to normative interpretation patterns in which authoritative convictions of unlawful behavior (morality in the narrower sense), authoritative convictions of reasonable behavior (standards of rationality) and upheld ideals of lifestyle form a coherent form (cf. Kettner 2015).

  4. 4.

    By “ethics” and “ethical” I mean a reflection that goes beyond questions of fact on all questions of norms and values ​​that are relevant to a recognized and lived ethos (regardless of what content). Such reflection can remain more or less implicit or, as in philosophical ethics, can be systematically developed very broadly. By “morality”, on the other hand, I designate a specific field within the broad area of ​​investigation of ethics, namely all recognized and lived normative convictions of rules and ideals (Gert 1998), which the members of cultural we-groups (ideally, all fellow human beings would be) in one plausible Expect a justifiable shared understanding of shared responsibility (co-responsibility) for avoiding improper behavior from one another (cf. Kettner 2002, 2014) or that they owe each other adequate consideration (Scanlon 2000).

  5. 5.

    "The relationship of patients with medically trained and licensed clinicians is at the very heart of CME [Clinical Medical Ethics]" (Siegler 2019, p. 17).

  6. 6.

    To put it more precisely: “Economization processes can be understood as systematic and thoroughgoing attempts to achieve desired results as target-oriented and as sparingly as possible. As long as economization is kept within reasonable limits that serve the necessary economic maintenance of hospital operations, it remains unproblematic in terms of medical ethics, with the exception of the risk of becoming independent and excessive savings constraints ('dead saving'). Commercialization means something more specific than Economization, namely the alignment of economic activities with monetary gain (or return) in an area to which this alignment was previously foreign. In the hospital, commercialization means a systematic incentive to align the diagnosis and indications not only with the well-being of the patient, but also with the expected income for the hospital ”(Working group“ Economization ”2020; discussion minutes from the Marburg Symposium on November 30, 2019, P. 1).

  7. 7.

    Krobath (2010, p. 578) sums up the Klagenfurt approach of the OE provisionally as follows: OE "is the context-sensitive organization of ethical reflection and decision as permanently renewed systems of understanding, negotiation processes and critical differences in and between organizations and networks about 'the good' in of our organized society, as it should and could become effective within the organization / networks concerned, through it in other environments and especially for those affected by it ”.

  8. 8.

    As “discursive power” I mean the ability of actors to use argumentative means to change the forces that accrue to our reasons because people think that the reasons they have are really good reasons (cf. Haugaard and Kettner 2020).

  9. 9.

    With reference to the important problem of an informative organizational taxonomy, which is unfortunately only sparsely addressed in the broad and diverse organizational science literature (for key works of this literature see Kühl 2015; as a standard textbook see Schreyögg and Geiger 2015; for state of the art see the magazine Organization Studies (OS)), the handbook by Apelt and Tacke (2012) stands out.

  10. 10.

    To substantiate the hypothesis that the commercial reshaping of doctor-patient interaction puts the professional medical ethos in the clinic in a miserable position, see Kettner and Loer (2011).

  11. 11.

    Even the developmental psychological differentiation of a number of levels of moral judgment could not deliver the long-cherished hope, especially in the research program of discourse ethics, of a single moral point of view superior to all other reasonable positions (Kettner 2018).

  12. 12.

    In the following I speak generically of “active organized social structures” in order to keep an eye on specific organizations of all kinds, institutions, communities, networks and to avoid narrowing down to “social systems” as dogmatized in the wake of Niklas Luhmann.

  13. 13.

    Starting with Kets de Vries (2001, orig. 1980). See also Cygler and Sroka (2014).

  14. 14.

    For an overview within the tradition of the Frankfurt School see Freyenhagen (2019). Recent reviews in Laitinen and Särkelä (2018), Honneth (2014, 1994).

  15. 15.

    We do not use the important but ambiguous concept of a function in a mathematical sense, but in a teleological (and e.g. indispensable for biology) sense. For the epistemological clarification of the teleological concept of function see Allen and Neal (2020).

  16. 16.

    Since the diagnosis of functional deficiencies and misery is not possible without well-founded evaluative and normative standards - this already applies mutatis mutandis to medical and clinical-psychological diagnosis (Hucklenbroich 2018) - institutional pathology, the core of the social pathology paradigm, opens up in theory , a field of questions unrelated to empirical i. S. of quantitative and qualitative methods that exclude everything normative are to be worked on, but only in ethics, understood as part of a critical theory of society (Kettner 2003).

  17. 17.

    The business economist Günter Ortmann has worked out a systematization that is important for my proposal to focus clinical OE on responsibility disorders. Ortmann (2011) uses many examples to prepare a repertoire of mechanisms of moral repression in and through organizations, but without elaborating the implications for OE as applied ethics.


  1. Allen C, Neal J (2020) Teleological notions in biology. In: Zalta EN (Hrsg) The Stanford encyclopedia of philosophy (spring 2020 edition). Accessed Jan 5, 2021

  2. Apelt M, Tacke V (2012) Handbook Organization Types. Springer, Wiesbaden

    Book Google Scholar

  3. Working group "Economization" in the Academy for Ethics in Medicine (2020) How about resistance? Medical options for action against the commercialization of the health care system. Protocol and lectures. Accessed Nov. 24, 2020

  4. Beauchamp T, Childress J (2019) Principles of biomedical ethics: marking its fortieth anniversary. Am J Bioeth 19 (11): 9-12

    Article Google Scholar

  5. Cygler J, Sroka W (2014) Structural pathologies in inter-organizational networks and their consequences. Procedia Soc Behav Sci 110: 52-63

    Article Google Scholar

  6. Donaldson T (2009) Compass and dead reckoning: the dynamic implications of ISCT. J Bus Ethics 88: 659-664

    Article Google Scholar

  7. Frewer A, Fahr U, Rascher W (Eds) (2008) Clinical Ethics Committees. Opportunities, Risks and Side Effects. Yearbook Ethics in the Clinic, Vol. 1. Königshausen & Neumann, Würzburg

    Google Scholar

  8. Freyenhagen F (2019) Social pathology and critical theory. In: Hammer E, Honneth A, Gordon PE (Eds) Routledge companion to the Frankfurt school. Routledge, London, pp 410-423

    Google Scholar

  9. Gert B (1998) Morality. Its nature and justification. Oxford University Press, Oxford

    Google Scholar

  10. Gert B (2007) Common morality. Deciding what to do. Oxford University Press, Oxford

    Google Scholar

  11. Hall RT (2000) An introduction to healthcare organizational ethics. Oxford University Press, Oxford

    Google Scholar

  12. Haugaard M, Kettner M (Eds) (2020) Theorising noumenal power. Routledge, London

    Google Scholar

  13. Heintel P (2010) Organization of Ethics. In: Krobath T, Heller A (eds) Organizing ethics. Handbook of Organizational Ethics. Lambertus, Freiburg, pp. 453-483

    Google Scholar

  14. Heubel F, Kettner M (2012) Praise of the profession. Ethik Med 24: 137-146

    Article Google Scholar

  15. Honneth A (1994) Pathologies of the Social. Tradition and topicality of social philosophy. In: Honneth (Ed) Pathologies of the Social. The task of social philosophy. Fischer, Frankfurt, pp. 9-69

    Google Scholar

  16. Honneth A (2014) The diseases of society. Approaching an almost impossible concept. WestEnd 11 11: 45-60

    Google Scholar

  17. Hucklenbroich P (2018) Illness as a theoretical concept of medicine: Differences between lifeworld and scientific concept of disease. J Gen Philos Sci 49 (1): 23-58

    Article Google Scholar

  18. Jacobs K, Kettner M (2016) On the theory of social pathologies in Freud, Fromm, Habermas and Honneth. IMAGO 4: 119-146

    Google Scholar

  19. Kets de Vries MFR (2001) Organizational paradoxes. Clinical approaches to management. Routledge, London

    Google Scholar

  20. Kettner M (2002) Morals. In: Düwell M, Hübenthal C, Werner M (Hrsg) Handbuch Ethik. J.B. Metzler, Stuttgart, pp 410-414

    Google Scholar

  21. Kettner M (2003) Critical Theory and the Modernization of Moral Engagement. In: Demirovic A (Ed) Models of Critical Social Theory. Traditions and Perspectives of Critical Theory. J.B. Metzler, Stuttgart, pp 77-100

    Google Scholar

  22. Kettner M (2008) Authority and organizational forms of clinical ethics committees. In: Frewer A, Fahr U, Rascher W (eds) Clinical Ethics Committees. Opportunities, Risks and Side Effects. Yearbook Ethics in the Clinic, Vol. 1. Königshausen & Neumann, Würzburg, S 15–28

    Google Scholar

  23. Kettner M (2011) Organizational ethics in hospitals - the next big thing? In: Kettner M, Koslowski P (eds) Business ethics in medicine. How Much Economy Is Good For Health? Wilhelm Fink, Munich, pp. 27-36

    Google Scholar