One of the most important functions of leadership and governance in an institution is to establish and articulate that institution's mission. This is usually written in a mission statement. An academic health center may have a mission that includes research, education, and patient care as equally strong components. A community hospital may point to excellent patient care and improvement of community health as its mission. A for-profit hospital or hospital chain may articulate excellent patient care and optimal return to shareholders as its mission. As one can imagine, this latter bipartite mission can lead to troubling conflicts of interest, which have been examined by ethicists in some detail (Gray).
The mission of an institution may also be articulated in the framework of its membership in a larger institution such as a church or religious network. Thus, some Catholic hospitals provide care to a large number of American patients (who are not necessarily Catholic), and their mission specifically derives from values espoused by the Catholic Church. Similarly, many other hospitals have emerged from religious systems because of the latter's commitment to helping the vulnerable and caring for the sick and suffering. Institutional missions may sometimes conflict with bedside ethical decisions, such as the decision to forgo life-sustaining therapy or to have an elective abortion. In these settings it is important for patients and providers alike to be clear about the underlying moral environment of the institution and the degree to which it may or may not be flexible on certain issues. Patients who feel strongly that they do not want care with those articulated standards should then have access to other institutions. Besides the question of abortion, the issue of forgoing life-sustaining treatment has been one of the most prominent in this kind of conflict. For example, the member of the patient's family who makes a decision about discontinuing nutrition and hydration in a comatose or unresponsive patient with far advanced dementing illness may find that the institution housing that patient does not allow nutrition and hydration to be withdrawn. If the underlying reason is fear of malpractice or liability concerns, it is sometimes possible for the institution to figure out a way to work together with and respect the wishes of the patient and family. If, however, the underlying reason is a moral or religious belief consistent with the underlying values of the governance of this institution, then it is less likely that a compromise can occur (Miles, Sinder, and Siegler).
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