"Integrity" and "compliance"

Health Progress, Sep/Oct 2001 by Dell'Oro, Robert

We hear a good deal about integrity and compliance in discussions of health care ethics today. Perhaps one should take a moment to inquire what those words mean.

THE TWO MODELS

"Compliance," as I will use the word here, has to do with the objective dimension of a person's (or organization's) relationship to rules and regulations. The rules and regulations are externally imposed. "Integrity," on the other hand, refers to the subjective side of the relationship. Integrity is a creature of the conscience. Whereas the phenomenon of compliance belongs primarily to the realm of law, integrity brings the question squarely back into the realm of ethics.

It may help us to explore what I call the adversarial and complementary models of compliance and integrity.

The Adversarial Model Examining the distinction between compliance and integrity can help us understand the difference between them. If we were to rank them on a moral scale, we would have to say that integrity is better than compliance. It is not altogether cheering to hear, for example, that a particular health care organization has been found compliant with the relevant rules and regulations. Those rules and regulations are, on one hand, evidence of the organization's sensitivity to ethics and, on the other, an indication of a troubling lack thereof.

Of course, distinguishing between integrity and compliance is not the same as separating them completely. After all, the very decision to abide by the rules is itself a moral decision and thus brings the legal realm into the moral one. Making the distinction is important, however, because it reminds us that the roots underlying moral integrity are deeper that those justifying a decision to comply with the law.

The Complementary Model Integrity and compliance programs have proliferated in today's economically stressed health care environment. Such programs have two functions:

* They proclaim the organization's commitment to the highest standards of morality

* They articulate the values upon which the organization wants its members, customers, employees, and stakeholders to conduct business

Yet, although corporate spokespersons speak with increasing frequency about "integrity" and "compliance," they do not necessarily mean by them the same things that other people do. To understand the corporate meaning of those words, one must know something about corporate reality. To understand what "integrity" means to a corporation, one must understand (and agree with) the capitalistic vision grounding the institution's purpose and function. To a forprofit institution's leaders, that capitalistic vision provides the ultimate criterion for judging the ethical correctness of the institution's actions. Integrity and compliance, then, relate in a complementary fashion to one another, as means to an end. From this perspective, to do business with integrity is to comply with the institution's goals-thus conforming to capitalistic values and principles that are essentially self-serving.

The morally significant difference between the adversarial and complementary models of compliance and integrity is this: The adversarial model is open, aware of a larger context, whereas the complementary model is self-contained. The adversarial model involves the recognition and appropriation of values beyond a particular organization. The complementary model involves values pertaining only to the organization itself. Under the complementary model, an activity can be said to possess integrity as long as it complies with the organization's purpose. No other, larger criteria exist.

A MODEL FOR HEALTH CARE INSTITUTIONS

Which model-the adversarial or the complementary-is more appropriate for health care institutions? Of course, choosing one or the other is not just a matter of semantic preference. It involves identifying the moral point of reference in the practice of medicine and, ultimately, the moral substance we decide to attach to health care.

For those who do not distinguish the delivery of health care from ordinary commerce, integrity and compliance are complementary. An organization that behaves so as to achieve a commercial purpose-that behaves efficiently, productively, and profitably-has integrity. From this perspective, a health care organization's integrity will depend, like that of any other commercial organization, on compliance with the capitalistic vision of the marketplace and with the forces of commercial culture.

Evidence suggests that the complementary model is becoming widespread. Many health care institutions have missions betraying a notion of integrity that is entirely a function of the maximization of profit. In such cases, integrity simply means compliance with the organization's economic interests.

But there are two problems with this use of the notion of integrity. First, it is based on values different from those that have traditionally driven medicine. Second, it is contradictory. An organization using the complementary model will often say that human well-being is its highest value; in fact, however, it must behave as if its own economic well-being were primary. In making service secondary to profit, the complementary model strips the notion of integrity of its moral substance. At the same time, it exploits the very idea of integrity, invoking it in a way that bespeaks moral seriousness and raises expectations of a moral character.