Written by Associate Professor Grant Davies, Health and Community Services Complaints Commissioner.
Health care complaints resolution is an important quality improvement mechanism in health care. Each of Australia’s States and Territories has a legally established complaints body which handles complaints that cannot be resolved at the service level. Those organisations achieve this through alternative dispute resolution mechanisms like mediation and conciliation and through investigation. Some States and Territories also have the capacity to prohibit unregistered health care workers through the adoption of a statutory code of conduct. (1)
How those organisations do their work is dictated, in large part, by legislation and international standards, (2) but very little has been written on the ethical underpinnings of such work and what has, relies on business and marketing examples. (3, 4)
Health care complaints resolution is a particular and specialised process. Frequently, complainants are vulnerable, seeking answers, highly distressed and grieving. Health service providers also experience anxiety, fear and irritation at being complained about. Complaints resolution bodies play an important role in evening up the structural power imbalance between complainants and service providers, creating and maintaining a level playing field, facilitating outcomes and establishing the body’s impartiality and independence. So understanding the ethical underpinnings of how to undertake this process is important. Because it is within a health care context, applying the principles of biomedical ethics is consistent. The commonly accepted principles of respect for autonomy, nonmaleficence, beneficence and justice, (5) as well as honesty also apply in the health care complaints resolution context. (6)
Autonomy and honesty
Beauchamp & Childress5 suggest that two conditions are essential for autonomy to exist; “(1) liberty (independence from controlling influences) and (2) agency (capacity for intentional action)”. Feinberg’s account of autonomy identifies four essential aspects to a person’s autonomy: the capacity to govern oneself, the actual condition of self-government, an ideal of character and the sovereign authority to govern oneself. (7) In a complaints resolution context, the notion of agency is critical. Respecting and acknowledging a complainant’s choices in relation to their capacity to participate, the outcomes they want and the role the complaints resolution organisation plays in resolving that complaint ensure fidelity to this principle. Sissela Bok has asserted that “deception, even for the most unselfish motive, corrupts and spreads”. (6) This is true in complaints resolution through the deliberate withholding of information or not being transparent in dealings with the parties, or the parties with each other. Good examples of this are service providers using technical language or jargon without ensuring the patient or family understand or complainants withholding information and not entering into complaints resolution processes in good faith. Much of the work of complaints resolvers involves expectation management of the outcomes both complainants and service providers want. These can be difficult conversations to have but they are critical in establishing trust and the independence of the complaints resolution organisation.
Nonmaleficence and Beneficence
The principle of nonmaleficence states one should avoid doing harm and the principle of beneficence states one should always do good. (8) Complainants are often vulnerable and highly distressed when making complaints as are those being complained about. Complaints resolvers have an obligation to ensure they do not cause greater distress through overly bureaucratic processes, uncaring communication styles or blind adherence to processes which do not take into account the specifics of the situation.
The particular notion of justice here is the Rawlsian notion of justice as fairness. (9) This concept is a social contract in which we all “…autonomously agree on how the basic institutions of our society must be structured so as to be just”. (10) This is particularly true for health complaints bodies as they are established under statute with rules and defined powers. Adherence to those rules as set out in legislation, as well as fundamental principles like the rules around procedural fairness, will help ensure a fair resolution is reached.
Autonomy, honesty, nonmaleficence, beneficence and justice are all ethical principles which play a crucial role in the resolution of health care complaints. Often the standards and legislative requirements of complaints resolution overshadow the more fundamental ethical underpinnings of this important quality improvement activity.
More work needs to occur to better articulate those underpinnings and, perhaps, the establishment of a code of ethics nationally for complaints bodies undertaking this type of work would assist in this endeavour.
1. COAG Health Council. Meeting Communiques. 2015, April 17. Retrieved from https://coaghealthcouncil.gov.au: https://www.coaghealthcouncil.gov.au/Portals/0/A%20National%20Code%20of%20Conduct%20for%20health%20care%20workers.pdf
2. ISO. Quality management – Customer satisfaction – Guidelines for complaints handling in organizations. Switzerland: ISO. 2018.
3. Tax, S. S., Brown, S. W., & Chandrashekaran, M. Customer Evaluations of Service Complaint Experiences: Implications for Relationship Marketing. Journal of Marketing. 1998. April.62, 60-76.
4. Bismark, M. M., Spittal, M. J., Gogos, A. J., Gruen, R. L., & Studdert, D. M. Remedies sought and obtained in healthcare complaints. BMJ Quality and Safety. 2011. 20(9), 806-810.
5. Beauchamp, T. L., & Childress, J. F. Principles of Biomedical Ethics (3rd ed.). New York: Oxford University Press.1994.
6. Bok, S. Lies for the Public Good. In P. Madsen, & J. Shafritz (Eds.), Essentials of Government Ethics. 1992. (pp. 218-232). New York: Meridian.
7. Feinberg, J. The Moral Limits of the Criminal Law. Vol. 1, Harm to Others. 1984. New York: Oxford Univesity Press.
8. Thiroux, J. P. Ethics – Theory and Practice (4th ed.). 1990. New York: Macmillan.
9. Rawls, J. A Theory of Justice. Cambridge: Harvard University Press. 1971.
10. Schneewind, J. B. Modern moral philosophy. (P. Singer, Ed.) Oxford: Blackwell. (1993).
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