Ethical decision making and health care managers
Ethical decision making and health care managers: Developing managerial profiles based on ethical frameworks and other influencing factors
A thesis submitted to the
Office of Research and Commercialisation
Queensland University of Technology
For the degree of Doctor of Philosophy (PhD)
2010
By Gian Luca Casali BAA, MBA
Ethical decision making and health care managers | ii
Keywords
Business ethics, ethical decision making, ethical profiles, health care managers,
moral philosophy, organisational culture, profiling, public sector, scale development.
Notes on Structure and Format of the Thesis
This thesis is for a PhD by publication. Chapters 2 to 7 consist of published papers,
where such papers have been published in a peer-reviewed journal or conference
approved by the Faculty Research Committee during the period of candidature, and
where the quality of such papers is appropriate to PhD-level.
This thesis meets the requirements outlined in QUT’s Manual of Policies and
Procedures, Appendix 9/14: Presentation of PhD Theses by Published Papers.
Where papers have multiple authorships, the candidate must be the principal author
of at least one of three papers (minimum number of papers is normally three) and
have written permission of the co-authors. The remaining sections (abstract,
introduction, background of the research, and conclusion) link and summarise the
research papers to provide a coherent narrative to the overall structure of the thesis.
Ethical decision making and health care managers | iii
Abstract
Whether the community is looking for “scapegoats” to blame, or seeking more
radical and deeper causes, health care managers are in the firing line whenever there
are woes in the health care sector. The public has a right to question whether ethics
have much influence on the everyday decision making of health care managers. This
thesis explores, through a series of published papers, the influence of ethics and other
factors on the decision making of health care managers in Australia. Critical review
of over 40 years of research on ethical decision making has revealed a large number
of influencing factors, but there is a demonstrable lack of a multidimensional
approach that measures the combined influences of these factors on managers. This
thesis has developed an instrument, the Managerial Ethical Profile (MEP) scale,
based on a multidimensional model combining a large number of influencing factors.
The MEP scale measures the range of influences on individual managers, and
describes the major tendencies by developing a number of empirical profiles derived
from a hierarchical cluster analysis. The instrument was developed and refined
through a process of pilot studies on academics and students (n=41) and small-
business managers (n=41), and then was administered to the larger sample of health
care managers (n=441). Results from this study indicate that Australian health care
managers draw on a range of ethical frameworks in their everyday decision making,
forming the basis of five MEPs (Knights, Guardian Angels, Duty Followers,
Defenders, and Chameleons). Results from the study also indicate that the range of
individual, organisational, and external factors that influence decision making can be
grouped into three major clusters or functions. Cross referencing these functions and
Ethical decision making and health care managers | iv
other demographic data to the MEPs provides analytical insight into the
characteristics of the MEPs. These five profiles summarise existing strengths and
weaknesses in managerial ethical decision making. Therefore identifying these
profiles not only can contribute to increasing organisational knowledge and self-
awareness, but also has clear implications for the design and implementation of
ethics education and training in large scale organisations in the health care industry.
Ethical decision making and health care managers | v
Contents
Keywords ii
Notes on Structure and Format of the Thesis ii
Abstract iii
Contents v
List of Tables ix
List of Graphs ix
List of Figures x
Abbreviations xi
Statement of original authorship xiii
Part 1 Thesis background, research context, and theoretical framework development 1
Chapter 1 Introduction 2
1.1 Background of the study 2
1.2 Aims and objectives 6 1.2.1 Objective 1 6 1.2.2 Objective 2 7 1.2.3 Objective 3 7 1.2.4 Objectives 4 and 5 7
1.3 Thesis outline: Linking the research papers to the research aim and objectives 8
1.4 Summary of the six research papers 13 1.4.1 Chapter 2 (Objective 1) 14 1.4.2 Chapter 3 (Objective 2) 14 1.4.3 Chapter 4 (Objective 3) 15 1.4.4 Chapter 5 (Objective 4) 15 1.4.5 Chapter 6 (Objective 3) 16 1.4.6 Chapter 7 (Objectives 4 and 5) 17 1.4.7 Chapter 8 Conclusion 17
Statement of contribution of co-authors for thesis by published papers 19
Chapter 2 Treating an unhealthy organisational culture: The implications for managerial ethical decision making of the Bundaberg Hospital Inquiry 20
2.1 Abstract 20
2.2 Introduction 20 2.2.1 Example 1: Poor decision-making processes and the employment of an
inappropriate staff member 23 2.2.2 Example 2: Poor decision-making processes and a culture of “cover up and
protection” 25
Ethical decision making and health care managers | vi
2.2.3 Example 3: Poor decision-making processes and workplace harassment and bullying 26
2.3 Organisational culture and its link to ethical decision-making processes 28
2.4 Aligning personal and organisational values: The Value Congruence Model 32
2.5 Moving beyond a value congruence model 36
2.6 Conclusion 37
Chapter 3 An evidence-based taxonomy of factors influencing ethical decision making: A critical response to the current literature 38
3.1 Abstract 38
3.2 Introduction 38 3.2.1 An overview of the literature on factors influencing ethical decision making 40
3.3 Classifying factors influencing ethical decision making 44 3.3.1 The degree of a factor’s influence on ethical decision making:
Ethical factors 45 3.3.2 The degree of a factor’s influence on ethical decision making:
Personal factors 47 3.3.3 The degree of a factor’s influence on ethical decision making:
Organisational Factors 54 3.3.4 The degree of a factor’s influence on ethical decision making:
External Factors 59
3.4 Summary of the literature review 60
3.5 A taxonomy of factors influencing ethical decision making 61 3.5.1 First dimension the ethical factors 63 3.5.2 Second dimension: the individual factors 65 3.5.3 Third dimension: the organisational factors 66 3.5.4 Fourth dimension: the external factors 67
3.6 Conclusion 68
Part 2 Pilot study 69
Introduction 69
The MEP sub-scales 71
Preamble 71
Chapter 4 A quest for ethical decision making: Searching for the holy grail and finding the sacred trinity in ethical decision making by managers 74
4.1 Abstract 74
4.2 Introduction 74
4.3 The study 78
4.4 Hypotheses 79 4.4.1 Hypothesis one (H1) 80 4.4.2 Hypothesis two (H2) 81
4.5 Measure 81
4.6 Sample 84
Ethical decision making and health care managers | vii
4.7 Results empirical analysis 84
4.8 Conclusion 90
Chapter 5 Creating managerial ethical profiles: An exploratory cluster analysis 92
5.1 Abstract 92
5.2 Introduction 92
5.3 Literature review 96
5.4 Method 99
5.5 Measure 99
5.6 Sample characteristics 101
5.7 Data analysis 101
5.8 Results 104
5.9 Discussion 105
5.10 Developing the Managerial Ethical Profiles 106 5.10.1 Profile 1: Duty Follower 107 5.10.2 Profile 2: The Chameleon 108 5.10.3 Profile 3: Guardian Angel 110 5.10.4 Profile 4: The Defender 111 5.10.5 Profile 5: The Knight 112
5.11 Conclusion 114
5.12 Possible practical application for the MEP scale 115
5.13 Future research and limitations 116
5.14 Footnote 117
PART 3: The main study results and conclusion 118
Chapter 6 Developing a multidimensional scale for ethical decision making 119
6.1 Abstract 119
6.2 Introduction 119
6.3 Literature review of tools for measuring ethical decision making 121
6.4 Theoretical assumptions for the MEP scale 127
6.5 Method 131
6.6 Research sample 134
6.7 Results 134
6.8 General discussion 138
6.9 Conclusion 141
Chapter 7 The relationship between managerial ethical profiles and individual, organisational, and external factors influencing the ethical decision making of health care managers in Australia 144
7.1 Abstract 144
7.2 Introduction 145
Ethical decision making and health care managers | viii
7.3 Methodology 147
7.4 Instrument 147
7.5 Sample characteristics 149
7.6 Procedure 149
7.7 Analysis 150
7.8 Results 151 7.8.1 Two-step cluster analysis results 151 7.8.2 Discriminant analysis results 153
7.9 Discussion 154 7.9.1 Managerial ethical profiles 154 7.9.2 Managerial ethical orientations 160
7.10 Conclusion 161
Chapter 8 Conclusion 164
8.1 Introduction 164
8.2 Key findings 164
8.3 Significance and practical application 171 8.3.1 Contribution to the current knowledge of factors influencing ethical
decision making. 171 8.3.2 Contribution to the current knowledge of tools that measure ethical
decision making in organisations 172 8.3.3 Contribution to the current knowledge of profiling in business 172
8.4 Limitations of the study and directions for future research 175 8.4.1 Continuing development and refinement of the MEP scale 175 8.4.2 Exploring the extent to which the MEPs can be applied 176 8.4.3 Examining the relationship between an organisation’s ethical position
and that of the outside community 177
References 179
Appendices 202
Appendix 1 MEP Questionnaire 202
Ethical decision making and health care managers | ix
List of Tables
Table 1.1 Summary of the pilot and main study 13 Table 3.1 List of academic journals reviewed 41 Table 3.2 A comparison of factors in reviews of the literature on ethical decision making
1962-2010 43 Table 3.3 Results of Cronbach Alpha analysis 72 Table 4.1 Mean differences between small-business managers, and academics and student in
relation to the eight ethical sub-scales 85 Table 4.2 Estimated marginal means for ethical decision making 88 Table 5.1 Comparison of HCA results (computed means) from Study 1 and Study 2 in
relation to the eight ethical sub-scales 105 Table 6.1 Summary of five tools for measuring ethical decision making 123 Table 6.2 MEP scale item loadings: Model A (eight-factor model) 133 Table 6.3 Results of Confirmatory Factor Analysis 135 Table 6.4 Correlation, average variance extracted (AVE), and shared variance estimates for
Model A 138 Table 7.1 Standardised means of the five MEPs: results of the two-step cluster, ANOVA,
and Scheffe 153 Table 7.2 Discriminant analysis 154 Table 8.1 MEPs and related scores on ethical sub-scales of health care managers in
Australia. 165 Table 8.2 Correlation between the five managerial ethical profiles and the three orientations
168
List of Graphs
Graph 4.1 Estimated marginal means 86
Ethical decision making and health care managers | x
List of Figures
Figure 1.1 Thesis framework: aim, objectives, and thesis parts and papers. 9 Figure 1.2 Part 2: The pilot study—aims and methods 10 Figure 1.3 The Study—aims and methods 12 Figure 3.1 Taxonomy of factors influencing managerial ethical decision making 62 Figure 5.1 The four temperaments: phlegmaticus, cholericus, sanguineus, melancholicus 93 Figure 5.2 Dendogram for HCA on academics and students 104 Figure 5.3 Dendogram for HCA on small-business managers 104 Figure 5.4 Duty Follower profile according to the eight sub-scales from the MEP scale 107 Figure 5.5 Chameleon profile according to the eight sub-scales of the MEP scale 108 Figure 5.6 Guardian Angel profile according to the eight sub-scales from the MEP scale 110 Figure 5.7 Defender profile according to the eight sub-scales from the MEP scale 111 Figure 5.8 Knight profile according to the eight sub-scales from the MEP scale 112 Figure 7.1 The Knight profile 155 Figure 7.2 The Guardian Angel profile 156 Figure 7.3 The Duty Follower profile 157 Figure 7.4 The Defender profile 158 Figure 7.5 The Chameleon profile 159 Figure 8.1 Knight orientation 168 Figure 8.2 Guardian Angel orientation 168 Figure 8.3 Duty Follower orientation 169 Figure 8.4 Defender orientation 169 Figure 8.5 The Chameleon profile 170
Ethical decision making and health care managers | xi
Abbreviations
AGFI Adjusted Goodness of Fit
ANOVA Analysis of Variance
ANZAM Australia and New Zealand Academy of Management
AVE Average Variance Extracted
AWB Australian Wheat Board
CFA Confirmatory Factor Analysis
CFI Confirmatory Fit Index
CMD Cognitive Moral Development
CR Composite Responsibility
DIT Defining Issue Test
EDM Ethical Decision Making
EPQ Ethics Position Questionnaire
HCA Hierarchical Cluster Analysis
MANOVA Multivariate Analysis
MBTI Myers-Briggs Type Indicator
MEP Managerial Ethical Profile
MES Multidimensional Ethics Scale
MJT Managerial Judgment Test
MVP Managerial Value Profile
QH Queensland Health
RMSEA Root Mean Square Error of Approximation
Small-business manager: The term represents a sample of small-business owners,
small-business managers, or both.
SRMR Standardised Root-Mean-Square Residual
TEQ Team Effectiveness Questionnaire
Ethical decision making and health care managers | xii
Publications
Casali, G. L., & Day, G.E. (2010). Treating an unhealthy organisational culture: the
implications of the Bundaberg Hospital Inquiry for managerial ethical
decision making. Australian Health Review, 34(1) 73–79.
Casali, G. L. (2009). Developing a multidimensional scale for ethical decision
making: The Managerial Ethical Profile (MEP). Paper presented at the 23rd
Annual Australia and New Zealand Academy of Management Conference
(ANZAM 2009), Southbank, Melbourne.
Casali, G. L. (2008a). An evidence-based taxonomy of factors influencing ethical
decision making: A critical response to the current literature. Proceedings of
the Eben Research Conference, Lille, France.
Casali, G. L. (2008b). Creating managerial ethical profiles: An exploratory cluster
analysis. Electronic Journal of Business Ethics and Organisation Studies,
13(2). pp. 27-34.
Casali, G. L. (2008c). The relationship between managerial ethical profiles (MEP)
and individual, organisational and external factors influencing the ethical
decision-making of healthcare managers in Australia. Paper presented at the
22nd ANZAM Conference (ANZAM 2008), Auckland, New Zealand.
Casali, G. L. (2007). A quest for ethical decision making: Searching for the Holy
Grail and finding the sacred trinity in ethical decision making by managers.
Social Responsibility Journal, 3(3), 50-59.
Ethical decision making and health care managers | xiii
Statement of original authorship
This thesis is submitted to the Queensland University of Technology in fulfilment of
the requirements for the degree of Doctor of Philosophy by publication.
This thesis represents my own work and contains no material that has been
previously submitted for a degree or diploma at this University or any other
institution, except where acknowledgement is made.
Signature ............................................
Gian Luca Casali
Date ............................................................
Ethical decision making and health care managers | xiv
Acknowledgements
Firstly I would like to thank Dr Trevor Jordan, my principal supervisor, for his
invaluable contribution, knowledge, and direction that he has provided me with, and
for his dedication and complete availability during these years.
I would also like to thank my Associate Supervisor, Professor Clive Bean, for his
technical support and for his thorough review of the final draft for this thesis and of
some of the papers included in this thesis.
I would also like to thank my Mum, Elisabetta; my Father, Mario; and my partner,
Natalia, for their constant support and tender loving care throughout these
challenging years.
Ethical decision making and health care managers | 1
Part 1 Thesis background, research
context, and theoretical framework
development
Background to research and literature review
Chapter 1 introduces the thesis, establishing the research question, and showing the
links between the research papers that form the chapters of the thesis.
Chapter 2, the first paper out of the six included in this thesis, establishes the
context that has prompted this research enquiry. Using Liedtka’s Value Congruence
Theory (1989), Chapter 2 discusses the implications for managerial ethical decision
making arising from the Bundaberg Hospital Inquiry.
Despite a strong code of conduct within Queensland Health, the Public Sector Ethics
Act 1994 (Queensland Government, 2010), and strong individual staff with good
values, the lack of fit between espoused organisational values and values in everyday
practice created an opportunity for rogue individuals to exploit the organisation for
personal gain. Given that the ethical decision-making capacity of health care
managers remains at the front line in the battle against unethical and unprofessional
practice, reflection on the Bundaberg Hospital Inquiry prompts the question: What
are the factors influencing managerial ethical decision making for health care
managers in Australia?
Ethical decision making and health care managers | 2
Chapter 3 aims to answer the question prompted by Chapter 2 by reviewing 40
years of literature on decision making, searching for these influencing factors.
Subsequently, it provides a multidimensional model for managerial ethical decision
making.
Chapter 1 Introduction
This introductory chapter outlines the background of the study and identifies the
current gap in the literature that was investigated. The main research aim and five
related objectives are then discussed. The introduction also provides evidence of the
scholarly and practical significance of the study. It is argued that this research is of
academic significance both in terms of its subject matter and methodology. It is also
posited that it is of significance beyond academia, particularly—but not limited—to
small, medium, and large health care organisations interested in improving the
ethical decision-making capabilities of their managers at all levels. Following the
discussion on the background and significance of the study, this chapter outlines the
thesis and the link between the six research papers, the research aim, and the five
objectives. Finally, as this doctorate is by publication, this chapter provides a
summary of the six papers included in this thesis.
1.1 Background of the study
Health care is a complex industry sector where patient safety is paramount, but
where other drivers—such as the ability to authenticate pharmaceuticals and medical
devices, track and trace products from manufacture to the patient, and improve the
supply chain—rank a close second. Ethical behaviours, decision making, and
leadership are becoming increasingly important in the health care industry due to the
Ethical decision making and health care managers | 3
switch of strategy focus from being traditionally “service oriented” to being more
“profit oriented” (Rolland, 2009, p. 51). Due to this recent switch, and with the
increasing pressure to satisfy the business model, the health care industry has been
undergoing a process of restructuring that has not been immune to unethical practices
and public attention (Rolland, 2009). Another element to add to the risk of unethical
behaviours in this industry is the fact that it has been service based for hundreds of
years, and therefore it is rich in precedents and references for law, medicine, and
ethics in clinical medicine, but poor in references for ethics in health care
management processes (Wingfield, Bissell, & Anderson, 2003).
The health care industry in Australia is a major part of the national economy with
total public and private expenditure on health care equalling approximately 10% of
gross domestic product and with more than $65 billion spent on health care each
year. More than 1,200 public- and private-sector hospitals in Australia employ over
half a million employees (AIHW, 2010). This industry is vital not only because of its
economic importance, but also due to its intrinsic significance directly related to
people’s well-being; therefore, it is at the centre of public scrutiny. The most
prominent issue facing managers in the health care industry is inadequate public
findings to match the growing costs of providing long-term care and occupancy
levels (Madas, 2000). This is the result of various political and regulatory,
economical, and social factors. It has been argued that not only are doctors
challenged by tricky ethical situations, but also that health care managers are
constantly facing ethical dilemmas (Galloro, 2000). Health care managers have to
deal with increasing tension between good business practice and the practice of good
medicine: a situation that, if mismanaged, could end in tragedy (Galloro, 2000).
Ethical decision making and health care managers | 4
Therefore, due to an increasing number of health care managers dealing with ethical
problems, and the importance of this industry, this thesis will investigate the factors
that influence ethical decision making.
Liedtka (1989) argued that the reality of the process through which individuals make
ethical decisions in organisations, and the importance of factors that influence the
decision-making process, remain largely a black box although ‘academics debate
theories, and consultants offer “how-to” solutions’ (p. 805). Therefore, this thesis
uses the current literature on factors influencing ethical decision making and
profiling techniques to provide a key to unlocking the black box of managerial
ethical decision making in the health care industry.
Profiling techniques are known widely for being applied to the area of criminal
justice, not only for their usefulness to that field, but also due to being heavily
publicised by television shows such as Cracker, Bones, CSI, Castle, and The
Mentalist. Criminal profiles are developed by using different factors such as gender,
ethnicity, race, age, personal history, abusive childhood, and peer pressure in order to
identify the characteristics of the perpetrators of specific crimes (Pollock, 2004).
Potential suspects are then identified on the basis of these profiles. However,
criminal justice profiling results in justifiable criticisms: questions of individuals’
rights, issues of profiles biased through prejudice and stereotyping, and the lack of
theoretical and empirical support for its reliability and usefulness in practice
(Pollock, 2004). These misuses of profiling in the criminal justice domain remind us
that the possible predictive capacity of profiling is always a matter of probability
rather than certainty. Profiling aims to discriminate between, not against, people.
Ethical decision making and health care managers | 5
Nevertheless, profiling is a valid and useful tool that has been applied in many
different areas for hundreds of years. Since the beginning of behavioural science,
researchers and practitioners have sought to classify people according to their
particular personality traits, with the aim of being able to predict their future
behaviour. Profiling is a classifying technique that groups individuals’ observed
physical, social, or psychological differences into a series of types, the behaviour of
which will be more or less predictable. One of the first recorded attempts at profiling
was by the Greek doctor Hippocrates (c.460–370 BCE), who developed four profiles
based on four factors, which he called “humours” (fluids).
Profiling is also being extensively applied in business on a number of different
occasions and for various purposes. For example, profiling techniques have been
used to profile consumers based on different characteristics such as their decision-
making styles (Sproles & Kendall, 2005), their need to retrieve information (Fan,
Gordon, & Pathak, 2006), and their motivation when purchasing via online auctions
(Hou & Elliott, 2010). Donald Trump (2004) provided another application of
profiling in business: understanding the psychology of people with whom he
negotiates has contributed to his success as a dealmaker. Another example of the
importance of psychological profiling in business is the notion that the potential
degree of success in a particular role can be linked to the possession of particular
personality traits such as being an extrovert, an introvert, intuitive, emotive, rational,
and judgmental. Thus, Briggs-Myers, McCaulley, Quenk, and Hammer, (1998)
developed a tool to psychologically profile people by a number of personality traits
called Myers-Briggs Personality Types. Another widely used profiling tool is the
Ethical decision making and health care managers | 6
Defining Issues Test (DIT) developed by Rest (1979, 1990), which is based on
Kohlberg’s Cognitive Moral Development theory (Kohlberg, 1969).
In summary, from the ancient Greeks to present day, the need to understand human
behaviour and render it more predictable and manageable has caused profiling
techniques to be applied to a broad range from business to medicine, and from justice
to online actions. Observing the number of scandals that have occurred over the past
10 years in the business sector, it is not surprising that there should be some renewed
interest in being able to understand and reduce the risk of individuals’ engagement in
unethical behaviours. As profiling techniques have already being applied
successfully in different areas for centuries, applying them, with ethical
considerations, to what managers are dealing with every day, is overdue.
1.2 Aims and objectives
The overall aim of this thesis is to apply profiling techniques to factors influencing
ethical decision making in order to profile health care managers in Australia. This
thesis seeks to achieve this overall aim with the following objectives:
1.2.1 Objective 1
Establish how important managerial ethical decision making is to health care
administration by examining a recent prominent example of alleged unethical
behaviour at the Bundaberg Hospital in Queensland.
(Chapter 2)
Ethical decision making and health care managers | 7
1.2.2 Objective 2
Develop an evidence-based taxonomy of factors influencing ethical decision making
based on the review of more than 40 years of literature on the topic.
(Chapter 3)
1.2.3 Objective 3
Develop a self-administered questionnaire based on the proposed evidence-based
taxonomy (Objective 2) and, by using confirmatory factor analysis, test its ability to
discriminate the ethical, personal, organisational, and external factors that influence
individual managers. Then, administer the questionnaire to a representative sample
of Australian health care managers.
(Chapter 4 and Chapter 6)
1.2.4 Objectives 4 and 5
Use profiling techniques to factors influencing ethical decision making of health care
managers in Australia, two main applications:
1.2.4.1 Objective 4
Use cluster analysis to develop managerial ethical profiles (MEPs) based on the
responses to eight ethical sub-scales of the questionnaire.
(Chapter 5 and Chapter 7)
1.2.4.2 Objective 5
Use discriminant analysis to extend the MEPs and determine how managers are
oriented to a range of individual, organisational, and external factors.
(Chapter 7)
Ethical decision making and health care managers | 8
1.3 Thesis outline: Linking the research papers to the research aim and objectives
In order to achieve the main aim and the five objectives of this thesis (Section 1.2), a
series of six papers have been included as chapters in this thesis (Figure 1.1). This
section explains the link between the papers and the objectives, how the papers
achieve the aim of the thesis, and their position in the structure of this thesis (Figure
1.1)
This thesis by published work consists of eight chapters, six of which are stand-alone
papers (Chapters 2–7) that have been published or accepted for publication; an
introduction (Chapter 1) and a conclusion (Chapter 8). The main aim of this thesis is
to profile Australian health care managers based on the factors that influence their
decision making as a whole. Each paper in this study plays an important role in
achieving one or more of the five objectives that have been identified as fundamental
to the main aim (Figure 1.1). Figure 1.1 clearly shows that each of the five objectives
build on each other (the white arrow represents the connection between the five
objectives) starting from Objective 1 and finishing with Objective 5. This thesis is
structured in three main parts: Part 1 (green circle) introduces the thesis, Part 2 (blue
circle) presents the results of the pilot study carried out to initially support the claim
of this thesis, and Part 3 (orange circle) reports on the results of the main study and
concludes that the main aim has been archived.
Ethical decision making and health care managers | 9
Figure 1.1 Thesis framework: aim, objectives, and thesis parts and papers.
Part 1 comprises three chapters, the first of which provides background to the
research, and a literature review on factors influencing managerial ethical decision
making. The second and third chapters are represented by two of the six papers
included in this thesis: the first establishes the importance of better understanding
managerial ethical decision making of health care managers by examining a recent
prominent example of alleged unethical behaviour at the Bundaberg Hospital in
Ethical decision making and health care managers | 10
Queensland (Chapter 2); the second reports on the development of an evidence-based
taxonomy of factors that influence ethical decision making from the review of the
past 40 years of literature in that area (Chapter 3).
Part 2 reports on the results from the pilot study for the thesis. It presents two papers
(Chapters 4 and 5) and an introductory section that explains the initial development
of the MEP questionnaire used for the pilot study (see Figure 1.2).
Figure 1.2 Part 2: The pilot study—aims and methods
The scope of the introduction of Part 2 is to outline the initial development of the
MEP scale that is otherwise discussed only in Part 3 with the results from the study
(441 health care managers). However, because the data for the pilot study has been
collected by using the ethical sub-scales of the MEP scale, an initial discussion of the
development of the scale is due in Part 2. Subsequent to the introduction to the MEP
scale, Chapter 4 provides an initial validation of the eight ethical sub-scales of the
MEP scale in terms of their capacity to discriminate between different cohorts of
people. In order to test the MEP scale’s psychometric capabilities, two cohorts were
chosen because of their significant differences. The first cohort was represented by
Ethical decision making and health care managers | 11
second-year nursing students and academics from the field of religion, philosophy,
ethics, and business ethics; the second cohort by small-business managers. The initial
results from this test reported significant differences between the two cohorts in
relation to the eight ethical sub-scales of the MEP scale, which provided the initial
step into proving its psychometrical capabilities.
Chapter 5 describes the results obtained from using profiling techniques based on
ethical factors (the MEP scale’s eight ethical sub-scales) to create MEPs (clusters).
Hierarchical cluster analysis (HCA) was performed on the data from the two cohorts
(academics and students, and small-business managers) in order to initially discover
possible patterns related to the eight ethical sub-scales of the MEP scale. In this
study, in order to be an acceptable cluster, it has to satisfy two criteria: internal
homogeneity and external heterogeneity, which means that internally the variation
between managers’ perceptions about the eight ethical sub-scales inside a cluster
must be minor, but, at the same time, these differences must be greater between
clusters. Results of the HCA performed on academics and students found five
clusters that fulfilled both requirements for being an MEP (cluster) for this study.
However, only four clusters were found for the small-business managers that
satisfied the two criteria for inclusion. An interesting fact that emerged from this
initial analysis was that the four clusters found in the second cohort were the same as
the four found in the first cohort and one was totally missing.
Part 3 builds upon the results of the pilot study (Part 2), as shown in Figure 1.3, by
further developing the new scale and further advancing the MEPs. This part of the
thesis comprised two papers that report the results from the main study—441 health
Ethical decision making and health care managers | 12
care managers in Australia—which is the main focus of this thesis. The first paper
(Chapter 6) further develops the MEP scale based on the multidimensional
framework proposed in Chapter 3, and the preliminary investigation based on the
initial scale development discussed in the introductory section of Part 2, the pilot
study).
Figure 1.3 The Study—aims and methods
This chapter not only discusses the scale development process for the MEP scale
(Objective 3), but also provides evidence that the schools of moral philosophy are
multidimensional in nature (Objective 3). Chapter 7 confirms that the data from a
sample of 441 Australian health care managers can be summarised by five MEPs.
In summary, Part 2 contains two papers that report the results from the pilot study
comprising two samples of 41 respondents each (academics and students n=41, and
small-business managers n=41) . On the other hand, each paper included in Part 3
Ethical decision making and health care managers | 13
reports the result of the main study, which is based on a cohort of 441 health care
managers in Australia. The pilot study of this thesis functioned to develop the MEP
scale and apply profiling techniques to factors that influence ethical decision making
(Table 1.1). In contrast, Part 3 further developed the MEP scale and the MEPs by
applying profiling techniques to factors influencing ethical decision making of a
number of Australian health care managers (see Table 1.1).
Table 1.1 Summary of the pilot and main study
PART 2 Pilot Study (n=41 x2)
PART 3 The Main Study (n=441)
MEP scale development
Chapter 4 tests the discriminant capabilities of the eight ethical sub-scales of the MEP scale, reporting significant different between two cohorts (41 academic and students, and 41 small-business managers).
Chapter 6 reports on the MEP scale development, and especially on the justification and support about the psychometrics capabilities of the eight ethical sub-scales by using the data collected from the main study on health care managers in Australia (n=441) .
Profiling creation
Chapter 5 explores the application of profiling techniques by using HCA on the results from two small cohorts 41 academic and students, and 41 small-business managers, based on the degree of influence that the eight ethical sub-scales of the MEP scale.
Chapter 7 reports on using a two-step profiling technique to the date collected from the main study about health care managers in Australia (n=441). Step one is to use two-steps cluster analysis on the results of the eight ethical sub-scales in order to identify significant different clusters (profiles), and then using discriminant analysis on the other influencing factors and the cluster membership previously identified.
1.4 Summary of the six research papers
This section provides a summary of the six papers included in this thesis,
concentrating in particular on the aspects that are related to the main aim and the
objectives of this thesis (Section 1.2).
Ethical decision making and health care managers | 14
1.4.1 Chapter 2 (Objective 1)
Casali, G. L., & Day, G.E. (2010). Treating an unhealthy organisational culture: The
implications of the Bundaberg Hospital Inquiry for managerial ethical
decision making. Australian Health Review, 34(1) 73–79.
This paper establishes the context that has prompted this research enquiry. Using
Leidtka’s Value Congruence Theory, the paper discusses the implications for
managerial decision making as a result of the Bundaberg Hospital Inquiry. Despite
the fact that there is a well definied code of conduct within Queensland Health and
the Public Sector Ethics Act 1994, and strong individual staff with good values, the
lack of fit between espoused organisational values and values in everyday practice
created an opportunity for rogue individuals to exploit the organisation for personal
gain. Given that the ethical decision-making capacity of health care managers
remains at the frontline in the battle against unethical and unprofessional practice,
reflecting on the Bundaberg Hospital Inquiry prompts the question: what are the
factors influencing managerial ethical decision making for health care managers in
Australia?
1.4.2 Chapter 3 (Objective 2)
Casali, L. G. (2008a). An evidence-based taxonomy of factors influencing ethical
decision making: A critical response to the current literature. Proceedings of
the Eben Research Conference, Lille, France.
This paper provides a critical analysis of more than 40 years of research on factors
influencing ethical decision making. As a general result of this analysis, there is a
large number of influencing factors that have been studied mostly independently,
Ethical decision making and health care managers | 15
which provides a strong foundation for further research on factors influencing ethical
decision making. Based on the survey of past research, this paper presents an
evidence-based taxonomy of factors influencing decision making as a guide to future
research. Four main categories have been developed based on the nature of the
influencing factors: ethical, individual, organisational, and external.
1.4.3 Chapter 4 (Objective 3)
Casali, G. L. (2007). A quest for ethical decision making: Searching for the Holy
Grail and finding the sacred trinity in ethical decision making by managers.
Social Responsibility Journal, 3(3), 50-59.
Chapter 4 uses the MEP scale’s eight ethical sub-scales to identify the degree of
influence that different ethical frameworks play on different people’s decision
making, and whether they differ depending on the industry under consideration. The
MEP questionnaire was distributed to a group of small-business managers (n=41),
and to university academics and students (n=41). The results indicate that there are
statistically significant differences in the ethical decision-making profiles of business
and non-business decision makers: an outcome that suggests that the eight ethical
sub-scales are able to discriminate between people.
1.4.4 Chapter 5 (Objective 4)
Casali, G. L. (2008b). Creating managerial ethical profiles: An exploratory cluster
analysis. Electronic Journal of Business Ethics and Organization Studies,
13(2). pp. 27-34.
Ethical decision making and health care managers | 16
This paper extends the analysis of the questionnaire data in the pilot study to an
investigation of MEPs by using the two different cohorts. After a brief discussion of
the importance of profiling as a predictor of human behaviour, statistical hierarchical
clustering techniques are used to provide a preliminary description of five MEPs:
Knights, Guardian Angels, Duty Followers, Chameleons, and Defenders. However,
only four of the five clusters were common to both cohorts, as the Duty Follower
was missing in the small-business manager. The study concluded that a cluster
analysis was a useful method for finding the natural grouping of poorly understood
influences of ethical principles in decision making and their representativeness in
common practice.
1.4.5 Chapter 6 (Objective 3)
Casali, G. L. (2009). Developing a multidimensional scale for ethical decision
making: The Managerial Ethical Profile (MEP). Paper presented at the 23rd
Annual Australia and New Zealand Academy of Management Conference
(ANZAM 2009), Southbank, Melbourne.
This paper develops an instrument, based on the multidimensional model developed
in Chapter 3, to measure the multiple influences on managerial decision making, and
reports on the validity and reliability of the survey instrument used to gather primary
data. The paper provides evidence of construct content validity and scale validity by
using a number of strategies including semi-structured interviews with experts, a
pilot study, and a larger study. Specifically, this paper demonstrates that variations in
ethical style can be better revealed by creating eight sub-scales to the four major
schools of moral philosophy: ethical egoism, utilitarianism, virtue ethics, and
deontology. The preliminary research confirms that ethical frameworks of individual
Ethical decision making and health care managers | 17
managers tend not to mirror the major schools or moral philosophy; rather, individual
managers combine the ethical schools each in their own way.
1.4.6 Chapter 7 (Objectives 4 and 5)
Casali, G. L. (2008c). The relationship between managerial ethical profiles (MEP)
and individual, organisational and external factors influencing the ethical
decision-making of healthcare managers in Australia. Paper presented at the
22nd ANZAM Conference (ANZAM 2008), Auckland, New Zealand.
At the outset, this final paper aims to replicate the results from Chapter 5 in terms of
finding the five MEPs in the Australian health care sector. It then aims to further the
knowledge about MEPs derived in Chapter 6 by testing the correlations between the
MEPs and the individual, organisational, and external influencing factors identified
in Chapter 3. This paper has confirmed the five MEPs from Chapter 6 across the
larger sample (n=441) of health care managers. In addition, it has advanced the
understanding of those five MEPs by fully analysing all of the influencing factors
suggested by the model in Chapter 3. As a result of this analysis, four functions (out
of the 32 items representing the other influencing factors) were identified using
discriminant analysis. However, only three of these four functions were significant in
terms of discriminating between the five MEPs.
1.4.7 Chapter 8 Conclusion
Although each paper establishes its own research question and conclusion, this
chapter concludes the thesis by summarising the overall findings, restating the
significance of the research project, and offering suggestions for further research.
Results from this study indicate that Australian health care managers draw on a range
Ethical decision making and health care managers | 18
of ethical frameworks in their everyday decision making, forming the basis of five
MEPs. Results from the study also indicate that the range of individual,
organisational, and external factors that influence decision making can be grouped
into three major clusters or functions. Cross referencing these functions to the MEPs
provides analytical insight into the characteristics of the MEPs. Identifying these
profiles can contribute to increasing organisational knowledge and self-awareness
and inform the design and implementation of ethics education and training in large-
scale organisations especially in the health care industry.
Ethical decision making and health care managers | 19
Statement of contribution of coauthors for thesis
by published papers
The authors listed below have certified that:
1. They meet the criteria for authorship in that they have participated in the
conception, execution, or interpretation, of at least that part of the publication in
their field of expertise.
2. They take public responsibility for their part of the publication, except for the
responsible author who accepts overall responsibility for the publication.
In the case of Chapter 2:
Casali, G. L., & Day, G.E. (2010). Treating an unhealthy organisational culture: the
implications of the Bundaberg Hospital Inquiry for managerial ethical decision
making. Australian Health Review, 34(1) 73–79.
Contributor Statement of contribution*
Gian Luca Casali
wrote the manuscript, literature review, and conclusion Signed:
Date
Gary E Day Provided expert insight into the paper, and edited the first version of the paper.
Principal Supervisor Confirmation
I have sighted e-mail or other correspondence from all Co-authors confirming their
certifying authorship.
Name Signature Date
Ethical decision making and health care managers | 20
Chapter 2
Treating an unhealthy organisational culture:
The implications for managerial ethical
decision making of the Bundaberg Hospital
Inquiry
2.1 Abstract
This paper explores the interplay between individual values, espoused organisational
values, and the values of the organisational culture in practice in light of a recent
Royal Commission in Queensland, Australia, which highlighted systematic failures
in patient care. The lack of congruence between values at these various levels
impacts on the ethical decision making of health care managers. The presence of
strong individual staff values and institutional ethics regimes, such as the Public
Sector Ethics Act 1994 (QH, 2010) and the Queensland Health Code of Conduct
(QH, 2006), are not sufficient to counteract the negative influence of informal codes
of practice that undermine espoused organisational values and community standards.
The ability of health care managers to make ethical decisions remains at the front
line in the battle against unethical and unprofessional practice.
2.2 Introduction
Early in 2005, a Commission of Inquiry into the operation of the Bundaberg Hospital
in Queensland, and, in particular, the conduct of one surgeon, found serious breaches
of clinical and professional practice. The range of issues identified, and the
Ethical decision making and health care managers | 21
subsequent recommendations by the Bundaberg Hospital Commission of Inquiry,
were not new for the health care sector (Davies, 2005). Many other jurisdictions have
had similar inquiries with similar outcomes and recommendations:
New South Wales: Campbelltown-Camden
Victoria: Royal Melbourne Hospital
Western Australia: Australia King Edward Memorial Hospital
The United Kingdom: Bristol Royal Infirmary
South Africa: TownHill Hospital
Canada: Winnipeg Health Sciences Center
Slovenia: Celje Hospital
Scotland: Glasgow’s Victoria Infirmary
New Zealand: Southland DHB and the Princess Mary’s Hospital
(Braithwaite, Travaglia, & Ledema, 2006).
Each inquiry concluded that the quality of care was below reasonable standards and
that the substandard care concerns were often raised by a few dedicated and altruistic
staff members. Communication was problematic between the hospital and the formal
controlling agency responsible for assuring the protection of patients, as well as
between the health care organisation, patients, and their relatives. There was a
breakdown in formal organisational procedures for reporting adverse medical events,
and there was a poor sense of teamwork and collaboration.
Despite repeated investigations into these systemic weaknesses, and subsequent
recommendations to prevent such incidents re-occurring, health systems continue to
experience critical incidents and catastrophic system failures. This chapter examines
some of the systemic failures, caused by individual and organisational values,
Ethical decision making and health care managers | 22
revealed in the Bundaberg Hospital Commission of Inquiry. Some prominent
examples of poor decision making highlighted by the Inquiry can be seen as
symptoms of an underlying pathology often misdiagnosed as simply a lack of
congruence between the values of individual managers and the organisation, with
either a healthy organisation being undermined by bad individuals or good
individuals being subverted by a bad system.
However, analysis of the situation using Liedtka’s Value Congruence Model
(Liedtka, 1989) is more revealing. This model has been used extensively by a
number of researchers who are interested in investigating organisational culture by
specifically looking at the nexus between individual and organisation values
(Edwards & Parry, 1993; Glover, Bumpus, Logan, & Ciesla, 1997; Liedtka, 1989,
1992; McDonald & Gandz, 2006; Posner & Schmidt, 1993). Specifically, the model
explains why, as in the case of the Bundaberg Hospital, the presence of strong
individual values among staff and strong espoused organisational values in line with
community expectations—backed up by legislation and ethics regimes—were not
sufficient to prevent an unhealthy situation from occurring. In particular, the lack of
congruence between the espoused values of the organisation and the values
expressed in everyday organisational practices illustrates how large organisations can
be exploited by rogue individuals.
Establishing congruence between espoused and in-practice values, which are so vital
to organisational health, will require values and ethics to be more intentionally and
systematically incorporated into managers’ everyday ethical decision making. The
Ethical decision making and health care managers | 23
following three examples taken from the Inquiry illustrate the contribution of poor
decision making to systemic failure.
2.2.1 Example 1: Poor decision-making processes and the employment of an inappropriate staff member
In late 2005, the Bundaberg Hospital Commission of Inquiry was superseded by the
Queensland Public Hospitals Commission of Inquiry (Davies, 2005), to which one
body of evidence, the initial reason for the investigation, was provided. The evidence
concerned the employment of, and alleged subsequent substandard care provided by,
Dr Jayant Patel (Foster, 2005). Between 1978 and 2005, first in the America (New
York and Oregon) and then in Bundaberg, Australia, Dr Patel was associated with a
number of adverse clinical outcomes, including deaths, mostly due to poor clinical
practice and negligence. In 1984, in Rochester, New York, Patel had been cited for
failing to properly examine patients before surgery (just as he later appeared to be
doing in Queensland between 2003 and early 2005), and as a result his surgical
practice was restricted (Morton, 2005). In addition, he was accused of falsifying
operating theatre reports; abandoning or neglecting patients in immediate need; and
harassing, abusing, or intimidating patients (Sandall, 2005).
Despite the documented shortcomings of his clinical practice, the falsification of his
application to practice medicine in Queensland, a lack of adequate reference checks
from the Medical Registration Board of Queensland, and no performance appraisal
during his appointment, Patel was appointed as the Head of Surgery at the
Bundaberg Hospital in 2003. After less than two years in the position and a long list
of complaints from both staff and patients about substandard surgical care and
treatment, the doctor was allowed to leave the country without answering questions
about anomalies in practice and registration.
Ethical decision making and health care managers | 24
The Queensland Public Hospitals Commission of Inquiry (Davies, 2005) heard
evidence that Patel remained in his position primarily for utilitarian reasons as the
hospital stood to lose substantial amounts of money from the Elective Surgery
Waiting List Reduction Program should he leave or be stood aside. Similarly, one
could question the decision-making processes within the Health Service District used
by the hospital to clinically review this surgeon’s competence and complication
rates. The Commission uncovered a litany of poor decision-making processes, from
the failure to properly check medical credentials, the inability to critically review
performance in light of staff and patient complaints, and a system that allowed a
suspect surgeon to continue practising so that the hospital met its surgical targets.
Clearly, these decision-making processes have led to substantial public distrust of the
local health system, poor clinical outcomes, the preventable deaths of a number of
patients, distress for patients and their families, and a huge expense for the
Queensland Government in undertaking a Royal Commission to investigate the
issues. At the heart of the problem was failure by health care managers to exercise
care for others by giving due attention to the harm principle when making decisions.
When employing a new medical staff member, Queensland Health failed to exercise
due diligence and its duty of care to not harm others, that is, patients and staff. This
occurred despite the presence of well-defined espoused organisational values in both
the Queensland Health Code of Conduct (QH, 2006) and the Public Sector Ethics
Act 1994 (Queensland Government, 2010), and strong shared values of individual
staff. If the principle of diligence and non-maleficence—not harming others—had
Ethical decision making and health care managers | 25
been applied when employing new staff, a credential check would have been
performed, and performed thoroughly.
2.2.2 Example 2: Poor decision-making processes and a culture of “cover up and protection”
The Bundaberg Hospital Commission of Inquiry clearly illustrates the destructive
effects of an organisational culture that in practice values covering up and protection
over those values—such as honesty, integrity, and duty of care—that are supported
both privately by the individual staff and publicly by the organisation. The
Bundaberg Inquiry itself resulted from the courageous action of one nurse, Toni
Hoffman, who refused to be silenced about the apparent clinical incompetence and
actions of one doctor. The situation highlights a breakdown in a major hospital
procedure relating to reporting an adverse medical event (Davies, 2005). It was only
after unsuccessfully following the organisational procedures to have the hospital
review Dr Patel’s practice and to prevent him from harassing patients, general staff,
and nurses that Hoffman decided to go public. As required by hospital procedures in
the case of a staff member wanting to report an adverse medical event, a ‘sentinel
event report’ (p. 450) must be filed and given to hospital officials—a procedure that
Hoffman followed correctly (Davies, 2005). However, her report was never passed
on. She subsequently decided to collect evidence of the doctor’s poor clinical
outcomes herself, detailing information about 14 cases and then sending the report to
the District Health Manager. Failing to have her concerns adequately dealt with both
at the hospital and district levels, this report was eventually provided to a State
Member of Parliament, who raised the matter on the floor of the House. This action
resulted in the Queensland Premier establishing the Bundaberg Hospital Commission
of Inquiry (Davies, 2005).
Ethical decision making and health care managers | 26
Clearly, despite the presence of written procedures and strong espoused
organisational values, in practice, the organisational culture leant towards
defensively protecting, at all costs, choices that had already been made, rather than
opening decisions up to scrutiny. Here, the vital workplace value of accountability
was missing.
2.2.3 Example 3: Poor decision-making processes and workplace harassment and bullying
According to evidence at the Inquiry, in practice, the organisational culture in
Queensland hospitals often manifests harassing behaviours that are out of sync with
the shared and espoused values of friendship, honesty, and compassion and care. In
conjunction with the allegations of substandard care, there was also evidence of a
culture of bullying in the workplace (Davies, 2005; Foster, 2005). The doctor at the
centre of the Inquiry was not the only one alleged to be bullying nurses and general
staff. During the Inquiry, it became evident that this behaviour was widespread at the
Bundaberg Hospital. This problem is not limited to this particular hospital or, indeed,
the health care sector (Davies, 2005; Foster, 2005). Workplace bullying is a serious
problem in Australia, as evidenced by the number of laws and policies that have been
put in place in recent times to address the phenomenon. A law in South Australia, for
example, created in 2005, has fines of up to AU$100,000 for employers who fail to
‘adequately manage’ bullying behaviours (Workplace Bullying, n.d, para 1). In the
UK, a study found that nurses are in the top three most bullied groups in the national
health sector, with one out of two nurses reporting bullying behaviours towards them
(Foster, Mackie, & Barnett, 2004). There are numerous studies that have addressed
bullying as a common and costly practice in organisations (Saunders, Huynh, &
Ethical decision making and health care managers | 27
Goodman-Delahunty, 2007; McMahon, 2000; Rayner & Cooper, 1997). It has been
estimated that workplace bullying in Australia costs $180 million in lost time and
productivity (Farrell, 2002); the cost is much higher in the United Kingdom: around
₤30 billion (Workplace Bullying, n.d). The Bundaberg Inquiry revealed that the
major reason for the large number of resignations of front line medical staff was the
existence of widespread intimidation, bullying, and victimisation (QH, 2005).
It is not hard to see that, apart from its direct negative psychological impact on staff
morale and lack of respect for persons, bullying behaviour seriously undermines
efficient and effective decision making. While it may be misguidedly aimed at
increasing compliance and efficiency, bullying not only promotes internal opposition
and subverts team cohesion but also undermines the rational basis of decision
making. As the Bundaberg Hospital case illustrates, there is a heavy toll paid in the
loss of staff and productivity. Such high staff turnover does not help to engender
commitment and consistency in ethical decision making. At a deeper level, bullying,
intimidation, and victimisation can be seen arising naturally in situations where there
is a lack of value congruence and where effective decision making guided by shared
values does not exist. Without the motivating power of shared values, direct
intimidation is used to achieve compliance.
While the Bundaberg Hospital example shows that when bad decisions have been
made the first reaction has often been to find a scapegoat to blame, bad decisions
have more likely been influenced by an endemic systemic malaise or unhealthy
organisational culture. However, it is not sufficient to shift the blame entirely to the
Ethical decision making and health care managers | 28
organisational level; rather, as Liedtka (1989) has argued, closer attention needs to be
given to the relationship between organisational and individual values in action.
The presence of strong individual staff values and strong espoused values—in line
with community expectations and backed up by legislation and ethics regimes—were
not, on their own, sufficient to ensure a healthy organisational culture and to prevent
unethical, possibly illegal behaviour in the Bundaberg Hospital. Somewhat
surprisingly, one review into the Queensland Health system, prompted by the events
at Bundaberg Hospital, even reported that ‘on occasions the Queensland Health
Code of Conduct had been used as a tool to bully or intimidate Queensland Health
staff’ (Foster, 2005, p. 58). It is plausible to suggest that when the values expressed
through everyday practices, such as bullying, contend with espoused values, such as
those embodied in the Public Sector Ethics Act 1994 (Queensland Government,
2010), and the Queensland Health Code of Conduct (QH, 2006), the health of the
organisational culture is weakened, and opportunities arise for individuals to
knowingly engage in wrongdoing without fear of reprisal.
2.3 Organisational culture and its link to ethical decision-making processes
When defining ‘unhealthy’ and ‘healthy’ organisational cultures it is useful to start
with a metaphor used by Aristotle when he posed the question: ‘What constitutes a
“good knife”?’ (Crisp, 2000). Aristotle defines goodness in terms of purpose. He
argued that the very function of a knife is to cut and, therefore, a good knife is a
sharp knife (Crisp, 2000). Similarly, it can be argued that the unique function of a
good organisational culture is to promote all those shared values, artefacts, and
behaviours that have been deemed acceptable within an organisation, region, or
Ethical decision making and health care managers | 29
country. Specifically, a healthy organisational culture actively promotes congruence
between the values of the organisation and the individuals working in it. Arguably,
then, an unhealthy organisational culture would be one that expresses values and
behaviours contrary to the shared values of staff members and the espoused
organisational values.
While Liedtka (1989) talks of ‘strong’ and ‘weak’ rather than ‘healthy’ and
‘unhealthy’ organisational cultures, the effects are similar. However, there is a subtle
difference. Liedtka has suggested that a strong culture refers to any culture that has a
strong ‘fit’ between individual and organisational values. Based on this definition,
the Mafia culture could well be a strong one, as long as the members’ values are in
line with the organisational values. A ‘healthy’ organisational culture, on the other
hand, does not simply refer to a culture that has a strong internal fit, but to a culture
that has a strong fit between the organisational and individual staff values and those
values widely shared in the broader community.
In diagnosing a ‘strong’ corporate culture we look for the existence of shared
meanings, beliefs, and values (Deal and Kennedy, 1982; Schein, 1985). The
more universal these understandings are among organizational members, the
stronger the culture. Conversely, a weak culture lacks such common themes.
Beliefs held by members are more diffuse (Liedtka, 1989, p. 806).
Strongly held individual values can aid decision making in the face of corporate
mixed messages, but ‘muddled organizational behaviour’ can also be exploited by
those ‘with little apparent sense of wrong-doing.’ (Liedtka, 1989).
Ethical decision making and health care managers | 30
Liedtka’s model has been extensively used by a number of researchers as a
framework to assess aspects of organisations, such as culture, work attitudes, ethical
practices, and motivation in terms of values congruence (Edwards & Parry, 1993;
Glover et al., 1997; Liedtka, 1989, 1992; McDonald & Gandz, 2006, Posner &
Schmidt 1993). Value Congruence Theory, as deployed by Liedtka (1989), has
focused mainly on the conflicts between individual and organisational values. In the
situation revealed in the Bundaberg Hospital Inquiry, however, there was a high level
of congruence between individual staff values and those espoused by the
organisation. It is the disjuncture between these individual and espoused values and
those put into practice in managerial decision making, that seem to have created the
opportunity for individuals to indulge in substandard practices with little awareness
of their wrongdoing.
Decisions are the building blocks of organisational climate or culture and can be
usefully described as choices guided by values. The consistent application of values
through decision-making procedures replicates the organisational culture across time
and space. Just as DNA encodes information from one generation to another, so too
is a recognisable organisational culture transferable from one generation to another
and from one place to another through the transmission of values. ‘Organizational
culture is the personality of an organization’ (Coomer, 2007; McNamara, 1999) and
it comprises the assumptions; values; norms; and tangible signs (artefacts) of the
organisation, members, and their behaviours (Burnes, 2004). The concept of culture
is particularly important when attempting to manage organisation-wide change
(Burnes, 2004; McNamara, 1999). Decision makers are coming to realise that,
despite the best-laid plans, organisational change must include not only changing
Ethical decision making and health care managers | 31
structures and processes, but also changing the corporate culture (Burnes, 2004).
Trevino and Nelson (2004), for example, have argued that, in setting the standards
for assessing the rightness of an action, not only are the individual values of the
decision maker important, but also other factors, such as organisational culture, play
a very important role.
Organisational culture is made up of values; more specifically, by preferences for
tangible and intangible outcomes, that are considered important by individuals (Dion,
1996). It is possible to identify three sources of values that equally can influence the
organisational culture and, indirectly, the managerial decision-making process: (1)
individual values, (2) espoused organisational values and (3) those values embedded
in the daily practice of the organisation. The individual values that might have been
present in the Bundaberg Hospital can be inferred from the results of a study of 1800
staff from two major tertiary hospitals undergoing amalgamation in Queensland, the
state in which the Bundaberg Hospital is situated and also part of the same
organization (Queensland Health). This study indicated five main staff values: care
and compassion, integrity, honesty, professionalism, and dignity (Mason & Wilson,
1999). Similar staff values were found by an independent review of the Queensland
health system (Foster, 2005). Also, due to the fact that the Bundaberg Hospital is a
public hospital, the two main sources of espoused organisational values were the
Public Sector Ethics Act 1994 (Queensland Government, 2010) and the Queensland
Health Code of Conduct (QH, 2006), which both promote values such as respect for
persons; integrity; respect for the law; and system of government, diligence, and
economy and efficiency.
Ethical decision making and health care managers | 32
Despite the existence of these espoused clues, however, the Queensland Public
Hospitals Commission of Inquiry into failings in the Queensland Health system
found that the actual organisational culture was far removed from these espoused
values. From the Queensland Public Hospitals Commission of Inquiry Report
(Davies, 2005; Foster, 2005) it appears that the organisational culture was, in fact,
characterised by bullying and a fear of standing up for issues that might not be in the
best interests of the organisation in fulfilling its core business of taking care for the
sick. The Queensland Health Systems Review Final Report noted that the staff of
Queensland Health referred to the organisational culture as ‘tribalism’, ‘tokenistic
consultation’, ‘no teamwork focus’, and ‘a culture based on power and control’
(Foster, 2005, p. 56). This is precisely the type of muddled organisational behaviour,
or lack of value congruence at the organisational level that Liedtka indicated was
open to exploitation (1989).
2.4 Aligning personal and organisational values: The Value Congruence Model
As previously discussed, there can be a significant gap between what staff personally
hold to be important values, what values are espoused by the organisation, and what
values are actually practised and supported within the organisation (Kabanoff,
Waldersee, & Cohen, 1995). As highlighted by the examples in section 2.2, staff are
often presented with a conflict between their individual values, the organisational
values publicly espoused, and those internally practised from day to day. Scott and
Hart (1979) suggest that, in such a situation, the principle of ‘organizational
imperative’ (p. 62) comes into play—employees have to obey the organisation and,
in doing so, personal values are put aside and organisational values prevail.
Ethical decision making and health care managers | 33
Liedtka provides a more in-depth analysis on the potential conflict between
organisational and personal values (1989). Using a Value Congruence Model,
Leidtka argued that individual values and organisational values can be either
‘consonant’ (clear and in line with each other) or ‘contending’ (ambiguous, and not
in line with each other) (1989, p. 808). Liedtka (1989) assessed the possible
combinations that can result from a two by two matrix (Figure 2.1) and concluded
that there are five possible ways that a manager can behave. Using this matrix it is
possible to map how a manager might make a decision in the five possible situations
that arise out of the four quadrants of the analytical matrix (Liedtka, 1989, pp. 808–
811). In Quadrant I, for example, the organisational values are clear to the manager;
however, the manager identifies an internal conflict (for example, between caring for
the patients and cutting costs). In Quadrant II, the organisational values are more
ambiguous (the company’s public statements sometimes conflict with internal
messages and realities) and conflict with personal values as well; therefore, the
manager in this situation would tend to make a decision according to how his or her
peers have done before (Groupthink). In Quadrant III, the manager has no internal
conflict (strong individual values), and the organisational values can either (A)
coincide or (B) differ from the manager’s values. Finally in Quadrant IV, which is
characterised by no internal conflict (strong individual values), but, in the presence
of ambiguous messages from the organisation, the manager would tend to fight for
his or her values (political behaviour). According to Liedtka’s model, however, if
organisation values are contending, strong individuals can exploit the situation to
their own advantage.
Ethical decision making and health care managers | 34
Figure 2.1 Individual and organisational values matrix
(Adapted from Leidtka, 1989)
Applying this matrix to the examples from the Bundaberg Hospital Commission of
Inquiry findings, it is clear that individual staff values such as care and compassion,
honesty, integrity, and professionalism, while congruent with the espoused values of
Queensland Health, were in strong conflict with the organisational values expressed
in the organisational culture—bullying and harassment, no teamwork, and tokenistic
consultation. The conflict between espoused organisational values and organisational
culture renders organisational values ambiguous. Respect for people; integrity; the
law; and the system of government, diligence, and economy and efficiency are the
most common espoused values promoted by the Queensland Health Code of Conduct
(QH, 2006) and by the Public Sector Ethics Act 1994 (Queensland Government,
2010). Internally, in practice, much less virtuous values are supported, such as
bullying and power games. In this scenario, some decision makers who lack coherent
individual values are likely to retreat to Quadrant II and be strongly influenced by
what their peers are doing rather than basing their decisions on espoused values or
even their own ethical frameworks.
Ethical decision making and health care managers | 35
Based on Liedtka’s (1989) model, a healthy organisational culture is one that fits into
Quadrant III, which is characterised by internally consistent individual values and
espoused organisational values consonant with those expressed in practice. To
further understand the validity of Liedtka’s (1989) model, we need to understand that
her Value Congruence Model does not assume ethical principles or values, only
consonant ones. Her model simply analyses the congruencies between the different
set of values (individual, organisation-espoused, and in-practice). The Mafia could
well be in the third quadrant because the different sets of values are consonant, but
overall it engages in unethical and illegal activities. As has been outlined, the
organisational culture revealed in the Bundaberg Hospital Commission of Inquiry is
at the exact opposite (Quadrant II) of Quadrant III because the individual and
organisational espoused values are promoting values such as friendships, care, and
compassion: values that are in conflict with those outlined by the organisational
culture, as illustrated by the report from the Queensland Health System Review,
which found that
…bullying, and intimidation on the one hand, and blaming and avoiding
responsibility on the other typify part of Queensland Health’s culture.
Descriptions such as “tribalism”, “tokenistic consultation”, “no culture of
teamwork” and a “culture of power and control” were repeated themes
throughout the consultation. (Foster, 2005, p. 56).
In view of this lack of value congruence, it is not surprising, then, that many poor
decisions were made in such an unhealthy organisational culture.
Ethical decision making and health care managers | 36
2.5 Moving beyond a value congruence model
To resolve the situation outlined in the previous examples, it is vital to move from
Quadrant II and Quadrant IV (Figure 2.1)—which characterise the conflict between
individual and espoused organisational values and the ones internally used—to
Quadrant III. Nevertheless, the issue goes beyond value congruence. A healthy
organisational culture is not only strong and coherent, it is a good in the ethical sense
as well. In order to successfully promote change and, more specifically, to change
corporate culture, it is paramount to adopt, in practice, foundational ethical values,
which are in line with the staff values and the espoused organisational values. Ethics
ought to be present in decision making at every level of the organisation. As
discussed, the main source of the values conflict is not the clash between individual
values and the espoused ones, but from the clash of these two with those informally
and internally adopted in an unhealthy organisational culture and become the driving
values in everyday decision making.
To achieve much better decision making in an organisation, the everyday influence
of these informal, but nonetheless powerful, unhealthy values must be replaced with
more ethical ones. This cannot be achieved by formal ethics regimes alone; after all,
the espoused values are often well in place and clear. There always remains a crucial
role for individual managerial decision-makers to play. However, changing the
values in hierarchical and geographically widespread organisations, such as health
care systems, is not an easy or quick task (Campbell, 2004). Every day, in different
locations around Queensland, hundreds of decisions are being made within the
Queensland Health and, more importantly, these decisions are being made by
individuals who may have consciously or subconsciously embedded unhealthy
Ethical decision making and health care managers | 37
values into their everyday decision-making processes. Therefore, in order to help
managers make better decisions, it is vital to provide them with a clear understanding
of the values that are not only shared across the organisation but are also meant to
guide their everyday decision making.
2.6 Conclusion
In an organisation such as Queensland Health, which employs in excess of 60 000
employees (QH, 2009), there would be hundreds of thousands of decisions being
made every day as well as manifold interpretations of the Queensland Health Code
of Conduct and the Public Sector Ethics Act 1994. It is not surprising that mistakes
can and do occur. The real tragedy revealed in the Bundaberg Hospital Commission
of Inquiry is not simply that Queensland Health did not practise what it preached, but
that this very lack of value congruence at the organisational level seems to have
allowed a rogue individual to opportunistically exploit the situation with devastating
consequences for staff and patients and their families.
Ethical decision making and health care managers | 38
Chapter 3
An evidencebased taxonomy of factors
influencing ethical decision making: A critical
response to the current literature
3.1 Abstract
A significant gap in the theoretical literature has been revealed by a critical analysis
of more than 40 years of research on factors that influence ethical decision making.
A large number of factors have been studied independently, and a few together, but
there are no genuinely multidimensional studies. Based on the survey of past
research, this paper presents a taxonomy of factors that influence decision making as
a guide to future research. Four main categories have been developed based on the
nature of the influencing factors: ethical, individual, organisational, and external.
This paper will discuss the implications and limitations for future research.
3.2 Introduction
In recent years, due to the increasing number of corporate scandals, researchers’ and
practitioners’ interest in business ethics has grown from only a few articles being
published in mainstream business journals to becoming a stand-alone discipline with
its own top-tier specialised business ethics journals such as the Journal of Business
Ethics, Business Ethics Quarterly, and Business Ethics: A European Review. One of
the areas that has received a great deal of attention is ethical decision making
(O’Fallon & Butterfield 2005; Loe, 1994). Research on ethical decision making in
Ethical decision making and health care managers | 39
business, however, is not a new topic. Raymond Baumhart (1969) published an
article about the importance of researching and teaching business ethics; Bohr and
Kaplan (1971) investigated the reasons behind health care workers’ protests and
concluded that the main issue was a conflicting view about the delivery of health
care services, or what the author referred to as a ‘complex ethical decision-making
issue’ (Bohr & Kaplan, 1971, p. 2234). Since these two papers were published, more
extensive research has been carried out on ethical decision making (O’Fallon &
Butterfield, 2005; Loe, Ferrell & Mansfield, 2000; Ford & Richardson, 1994).
Different approaches have been taken: some researchers developed models to
describe ethical decision making (Ferrell, Gresham, & Fraedrich, 1989; McDevitt,
Giapponi, & Tromley, 2007; Rest, 1979; Trevino, 1986); others focused on how to
implement ethical regimes such as codes of ethics in organisations (Svensson &
Wood 2007; Coughlan, 2005; Wood, 2000). A great deal of research has also been
published on the factors that can influence ethical decision making (O’Fallon &
Butterfield, 2005; Loe et al., 2000; Ford & Richardson, 1994). To date, however, no
research has collated all of these influencing factors and mapped them into a
taxonomy that can help managers better understand the complex construct of ethical
decision making. Therefore, the aim of this paper is to bring the current knowledge
about factors influencing ethical decision making to the next level by developing a
comprehensive taxonomy based on a critical review of more than 40 years of
relevant literature. To develop this taxonomy, a three-step process has been followed.
The first step is to provide an overview of the literature on factors influencing ethical
decision making, the second step is to classify factors influencing ethical decision
making into mutually exclusive categories, and the last step is to discuss their degree
of influence on ethical decision making.
Ethical decision making and health care managers | 40
The following section will discuss in detail the three developmental steps towards the
evidence-based taxonomy of factors influencing ethical decision making.
3.2.1 An overview of the literature on factors influencing ethical decision making
To cover the literature to date on factors influencing ethical decision making, this
paper combines the results of three major reviews of ethical decision-making
literature from 1962 to 2003 and an additional review of the remaining research from
2004 to 2010 (Table 3.2). The three major reviews incorporate more than 300 articles
from the literature on factors influencing ethical decision making in business from
prominent academic journals in the field of management, marketing and psychology
(Table 3.1).
Ethical decision making and health care managers | 41
Table 3.1 List of academic journals reviewed
Journal title Journal title Journal title
Academy of Management Journal
Strategic Management Journal
Organizational Behaviour and Human Decision Processes
Business Ethics Quarterly Journal of Business Research
Journal of Business Research
Journal of American Academy of Business Cambridge
Accounting Auditing and Accountability Journal
Journal of Business Ethics Public Opinion Quarterly
Journal of Organizational Behaviour
Journal of Counselling and Clinical Psychology
International Journal of Management
Journal of Education for Business
Journal of Macromarketing Journal of Management Studies
International Philosophical Quarterly
Journal of Management Issues Journal of Applied Social Psychology
Journal of Selling and Sales Management
Journal of Marketing Administrative Science Quarterly
Research in Organizational Change and Development and Business and Societies.
Journal of Research in Personality
Human Relations Academy of Management Review
Managerial Auditing Journal European Journal of Marketing
Journal of Academy of Marketing
The additional review incorporates 98 articles published between January 2004 and
January 2010 from academic journals similar to the previous reviews. O’Fallon and
Butterfield (2005), reviewing the empirical literature on ethical decision making
published between 1996 and 2003, found that 174 studies had been carried out.
Comparing these findings with earlier studies by Ford and Richardson (1994) and
Loe et al. (2000), it is clear that interest in ethical decision making is on the rise
(Table 3.2). What is important to note is that 273 articles have been published
between 1996 and 2010, while only approximately 110 were published between 1961
and 1994, suggesting that research interest on factors influencing ethical decision
making has more than doubled in the past 15 years.
Ethical decision making and health care managers | 42
All of the studies presented by the three reviews (O’Fallon & Butterfield, 2005; Loe
et al., 2000; Ford & Richardson, 1994) as well as the one that this paper has provided
(Table 3.2) are focused on ethical decision making in the business arena. However,
they differ in the method used to test theory, the factors tested, and the sample used.
In relation to the methods used, around half of the studies used responses to
scenarios, vignettes, or ethical dilemmas purposely developed by the researchers; the
next most common method was questionnaire research (O’Fallon & Butterfield,
2005; Loe et al., 2000; Ford & Richardson, 1994). A significantly smaller number of
studies asked respondents about ethical dilemmas that they have encountered at their
workplace (Marshall & Dewe, 1997), or asked the respondent for a self-assessment
of their own ethical behaviour in the workplace (McCabe, Trevino & Butterfield,
1996).
The factors surveyed range from individual factors such as age, gender, education,
and stage of moral development (O’Fallon & Butterfield, 2005; Ford & Richardson,
1994) to organisational factors such as organisational climate (Victor & Cullen,
1988), organisational size (Browning & Zabriskie, 1983), and codes of ethics
(Robertson & Schlegelmilch, 1993). Different cohorts have been targeted by
researchers to test their constructs, with the majority being either managers and
professionals samples (Jackson, 2000; Murphy, Smith & Daley, 1992) or students
(Trevino & Youngblood, 1990; Hegarty & Sims, 1979).
Ethical decision making and health care managers | 43
Table 3.2 A comparison of factors in reviews of the literature on ethical decision making 1962-2010
Factors influencing EDM Ford & Richardson: from 1972 to 1992
Loe et al.: from 1961 to 1994
O’Fallon & Butterfield: from 1996 to 2003
Casali: from 2004 to 2010
Religion 3 3 10 11
Nationality 6 0 25 18
Sex/gender 13 26 49 24
Age 8 15 21 7
Education, Job satisfaction, and Work experience
23 16 41 19
Personality values 3 10 13
Locus of control 2 4 11 4
Role of conflict ambiguity 1 ‐
Authority 1 0 5
Cognitive moral development 6 23 3
Philosophy/value orientation 2 21 42 26
Significant others 11 9 1
Peer group influence 5 2
Top management influence 4 7
Rewards‐sanctions 4 15 4
Codes 9 17 9
Ethical conflict 1 2
Organisational culture or climate 1 18 11
Organisational effect 5 1
Organisation size 3 1
Organisation level 3 6
Industry types 3 10
Business competitiveness 2 1
Total* 102* 154* 200* 175*
* Totals do not indicate the total number of articles. They represent the total number of findings by each independent variable (influencing factor). The total number of studies included is around 380. Also, the reviews by Ford & Richardson and Loe et al. cover overlapping time periods.
While these studies have greatly contributed to the current knowledge about factors
influencing ethical decision making—by bringing specific information about the
degree and nature of influence that each of these factors has on ethical decision
making—a common denominator across all of the studies is their narrow scope of
Ethical decision making and health care managers | 44
analysis; only a few factors have been tested together at any given time. Managerial
ethical decision making, however, is a complex and multidimensional process,
strongly characterised by subjective interpretation and intricate combination of
different factors (Bazerman, 2005). Therefore, as a first step to addressing the lack of
a multidimensional approach in the existing research, this study presents an
evidence-based taxonomy that takes into consideration the large number of factors
that can influence ethical decision making.
3.3 Classifying factors influencing ethical decision making
To give structure and clarity to this evidence-based taxonomy, it is important to
classify all of these influencing factors into mutually exclusive categories based on
the nature of their influence. For the purpose of this study, four mutually exclusive
categories will be used to summarise the large number of influencing factors: ethical
factors, individual factors, organisational factors and external factors. These four
categories encompass all of the possible influencing factors: they cover all factors
that are of an ethical or moral nature; all factors that are part of the individual such as
age, gender, and education; all factors related to the organisation such as code of
ethics and training; and all factors that are external to the above categories such as
economic, political, social, and competitive.
These four categories do not only exhaustively summarise all of the possible factors
influencing ethical decision making, but also reflect categories that have been used in
many models of ethical decision making such as: institutional factors (James, 2000),
ethical philosophies (Stead, Worrell & Stead, 1990), personal factors (Painter-
Morland, 2001), organisational actions (McDonald & Nijhof, 1999), individual level
Ethical decision making and health care managers | 45
(McDonald & Nijhof, 1999), external forces (Stead et al., 1990), organisational
factors (Stead et al., 1990), individual factors (Ferrell, Gresham & Fraedrich, 1989).
These four categories also reflect the three levels of influence that are commonly
discussed in decision making: micro (individual), meso (organisational), and macro
(society/external) (Dopfer, Foster & Potts, 2004; Erez & Gati, 2004; Enderle, 1997).
These three levels are further supported by the combination of three previously
discussed reviews of the literature on ethical decision making and models of ethical
decision making. Three literature review papers (Table 3.2) have used categories
such as individual/personal and organisational to summarise the influencing factors
(O’Fallon & Butterfield, 2005; Loe et al., 2000; Ford & Richardson, 1994). The
following section discusses in detail each of the factors influencing ethical decision
making and their degree of influence by the categories previously outlined.
3.3.1 The degree of a factor’s influence on ethical decision making: Ethical factors
It is important to note that the research emphasis on ethical factors (philosophy and
value orientation) has increased dramatically in the past 10 years: studies increased
in number from only two studies reported by Ford and Richardson (1994), 21 studies
reported by Loe et al. (2000), 42 studies reported by O’Fallon and Butterfield (2005),
to 26 studies being done within the past five years. Table 3.2 suggests that ethical
factors have moved from being the least researched topic (Ford & Richardson, 1994)
to being the second most researched one (Loe et.al, 2000; O’Fallon & Butterfield,
2005). This significant increase of research into ethical factors is the main reason for
ethical factors to be included in this study’s proposed taxonomy as a stand-alone
category rather than as an individual factor.
Ethical decision making and health care managers | 46
The range of ethical factors studied has also increased over the years. For example,
only two studies on ethical factors were reported by Ford and Richardson (1994),
which produced mixed results about the influence that economic and political values
have on ethical decision making. However, O’Fallon and Butterfield (2005) have
reported that idealism and deontology generally influence ethical decision making in
a positive way—supporting some of the findings of previous limited research—and
also that economic factors are negatively related to ethical decision making. In recent
years, researchers have expanded their research scope on this matter by looking at
different ethical factors, a situation that has revealed a number of interesting results
such as Bhuyan’s (2007) support of the important role that individual virtue and
strength of character play on ethical decision making, and (Palermo & Evans, 2007)
suggestion that different personal values were significant predictors of reported
behavioural choices on respective ethical scenarios. In their study of small business
managers, Marta, Singhapakdi, and Kraft (2008) found that neither idealism nor
relativism were significant predictors of a small business manager's ethical
intentions, a result that may suggest that what determines ethical behaviour for small
business managers is not an individual's personal moral philosophy, but the
individual's specific attitude toward specific ethical situations. Jewe (2008) was
interested in ascertaining the effectiveness of ethics courses on influencing individual
moral values, and suggesting that current courses have limited value in affecting
ethical attitudes. Also, Fritzsche and Oz (2007) found a significant positive
contribution of altruistic values to ethical decision making and a significant negative
contribution of self-enhancement values to ethical decision making. Vitell and
Patwardhan (2008) discovered that marketing practitioners from United Kingdom,
Ethical decision making and health care managers | 47
Spain, and China use perceived harm construct (e.g. magnitude of consequences,
probability of effect, temporal immediacy, and concentration of effect) to determine
intentions in situations involving ethical issues. West (2008) provided a discussion
using a model based on Jean-Paul Sartre’s existentialism—the concept of individual
freedom and responsibility or what he calls subjective experiences and personal
situations. Another factor that has been studied is decision-making support system,
which can provide some guidelines to people in dealing with ethical dilemmas
(Mathieson, 2007). Also, individual mood has been found to influence ethical
decision making, and, more specifically, that negative mood is associated with
decreased intention to act ethically (Curtis, 2006).
3.3.2 The degree of a factor’s influence on ethical decision making: Personal factors
In this study, personal factors are those factors that are directly related to the
individual decision maker and that can influence ethical decision making. Ford and
Richardson (1994) argue that these factors can be sub-divided into two groups: (1)
individual factors related to birth such as gender, nationality, age, and (2) individual
factors related to human development and interactions with others such as religion,
employment, cognitive moral development (CMD), education, and professional
experience.
Starting with those individual factors that are directly related to birth, the first one is
gender or sex. The findings from three different reviews of the effects of gender on
ethical decision making are mixed. For example, Ford and Richardson (1994)
reported that of 14 studies on gender, seven concluded that, in some situations,
Ethical decision making and health care managers | 48
females were more likely than males to act ethically, while the remaining seven
studies did not find any differences. Loe et al. (2000) counted 26 studies that have
discussed gender in relation to ethical decision making. They found that the majority
of them did not establish any major differences between male and female behaviour;
only a few of the studies suggested that females act slightly more ethically then
males. O’Fallon and Butterfield (2005) also reported that out of 49 studies on gender
and ethical decision making, most commented that there are few or no significant
gender differences. In the most recent literature, the findings seem to be more
consistent (O’Fallon & Butterfield, 2005) in relation to the degree of influence that
gender plays on ethical decision making; the vast majority of the studies found
gender influential (Bampton & Maclagan, 2009; Bernardi & Guptill, 2008; Lund,
2008; Wilborn, Brymer, & Schmidgall, 2007; Ritter, 2006; Scott-Hunt & Lim, 2005;
Doty, Timkiewicz, & Bass, 2005; Roxas & Stoneback, 2004; Kujala & Pietilainen,
2004), only two studies found it non-influential (Hartman, Fok, & Zee, 2009; Marc
& Vera, 2006), and three studies have yielded mixed results (Nguyen, Basuray,
Smith, Kopka, & McCulloh, 2008; Valentine & Rittenburg, 2007; McCabe & Rhea,
2006). For example, Hartman, Fok, and Zee (2009) found significant gender
differences in both reported levels of ethical behaviour and in approach to ethical
decision making, with males being more willing to engage in unethical behaviours
than female.
Another individual factor is nationality; however, its effects on ethical decision
making are also ambiguous. Of 25 studies reviewed by O’Fallon and Butterfield
(2005), five by Ford and Richardson (1994) and six from Loe et al. (2000), there
have been either mixed results or reports of no significant differences across the
Ethical decision making and health care managers | 49
different cultures. Some studies pointed out differences such as: US managers rating
ethical issues higher than UK managers (Robertson & Schlegelmich, 1993), cultural
environments affecting the individual perception of ethical situations (Armstrong,
1996), and French managers expressing more faith, compared to others around the
globe, that codes of conduct are an important tool in promoting ethical behaviour
(Becker & Fritsche, 1987). Once again, recent research is less ambiguous about the
importance that nationality plays on ethical decision making, with only one study
reporting no significant findings (Mustamil & Quaddus, 2009), and two that have
yielded mixed results (Singh, Vitell, Alkhatib & Clark III, 2007; Knapp &
Vandecreek, 2007). However, most of the research has supported that nationality is
an influential factors in ethical decision making (Patel & Schaefer, 2009; Oumlil &
Balloun, 2009; Beekun, Hamdy, Weaterman, & Hassebelmaby, 2008; Donald, 2006;
Frame & Williams, 2005; Srnka, 2004). For example, in a recent paper by Oumlil
and Balloun (2009) significant differences were found between American and
Moroccan managers in terms of their predisposition to make ethical decisions, and
Donald (2006) argued that ethnic culture serves as one determinant in classifying a
particular action as either ethical or not ethical.
Using Ford and Richardson’s (1994) sub-division, the final individual factor related
to birth is age. Again, there are mixed results. For example, only three out of eight
studies reviewed by Ford and Richardson (1994) revealed any difference between
younger and older people in relation to ethical decision making; although, one of
these three studies (Browning & Zabriskie, 1983) argued that younger purchasing
managers were more ethical than older ones. Loe et al. (2000), however, had more
promising results: out of eight studies not previously included in Ford and
Ethical decision making and health care managers | 50
Richardson’s (1994) paper, all but one showed a significant correlation between age
and ethical decision making. Two of the seven studies that have been reviewed by
Loe et al. (2000) found that older people and those later in their careers acted more
ethically than younger ones (Kelley, Ferrell, & Skinner, 1990; Barnett & Karson,
1989). However, in the literature review on ethical decision making by O’Fallon and
Butterfield (2005), there are again mixed results, with five studies arguing that there
was a negative relation; eight, no relation; and six, a positive relation. Also, there are
mixed results from the most recent literature: two studies (Shawver & Sennetti, 2009;
Callen-Marchione & Ownbey, 2008) found significant support of the influence of
age on ethical decision making, one study yielded mixed results (McMahon &
Harvey, 2007), and one study found no significance (Almerinda, 2004). The aim of
the study that yielded mixed results was based on manipulated and perceived moral
intensity on ethical judgment (McMahon & Harvey, 2007). The expected findings
were that, in between-subjects studies, participants would judge actions taken in
manipulated high moral-intensity scenarios to be less ethical than the same actions
taken in manipulated low moral-intensity scenarios. The findings were mixed for the
effect of perceived moral intensity.
With respect to the individual factors related to human development and interactions
with others, the first one is religion. Eight out of 10 studies have reported that
religion had a positive influence on ethical decision making (O’Fallon & Butterfield,
2005). This is a far better result than that found by Ford and Richardson (1994), and
confirmed by Loe et al. (2000), where only one out of four studies found any
relationship. A study carried out by Giacolone and Jurkiewicz (2003) found that
individual perceptions as to whether a questionable business practice is ethical or
Ethical decision making and health care managers | 51
unethical differ instrumentally according to the degree of individual spirituality of
the respondents. Recent studies vary on the degree of influence that religion has in
ethical decision making, from weak (Kurpis, Beqiri, & Helgeson, 2008) to strong
(Vitell & Bing, 2009; Angelidis & Ibrahim, 2004; King, 2007), with Keller, Smith,
and Smith (2006) finding that religion was the strongest factor influencing ethical
decision making in their sample. Another interesting argument about the importance
of religion in ethical decision making is provided by Young (2007). He discusses the
important role that fiduciary duties, based on Judaeo-Christian biblical writings and a
theory of office descending from Cicero and Roman legal arrangements, plays on
ethical decision making (Young 2007).
Kohlberg’s Cognitive Moral Development (CMD) theory is another individual factor
which is part of the subgroup of factors related to human development and
interactions with others. CMD has been extensively tested in the literature. Between
1996 and 2003, there were at least 23 research studies exploring the relationship
between CMD and ethical decision making that found a positive relationship. This
number represents more than 10% of the total studies examined during that period
(O’Fallon & Butterfield, 2005). It has been argued that the higher the stage of CMD,
the higher the likelihood of making an ethical decision. Out of 23 findings reported
by O’Fallon and Butterfield (2005), 19 supported the idea that CMD influenced
ethical decision making. Fifteen of these studies encountered a positive relationship
between the stages of moral development and the likelihood of making an ethical
decision. For example, Bateman, Fraedrich, and Iyer (2003) found that there is a
weaker influence in relation to moral judgment when cost benefit-based reasoning
was used rather than rule-based reasoning. On the other hand, Au and Wong
Ethical decision making and health care managers | 52
(2000)—based on their investigation of professional accountants in Hong Kong—
argued that CMD has an impact on ethical decision making. However, they also
argued that the CMD can be influenced by other factors such as the Guanxi.
Generally, the term Guanxi in Chinese means ‘relationships’; however, in a business
sense, it refers to those business networks that are extremely important when dealing
with Chinese corporations (Au & Wong, 2000). Most recent literature on CMD’s
influence on ethical decision making has found that the level of ethical maturity of
African-American business professionals was not significantly different based on
age, gender, and ethical training; however, it was significant in relation to formal
education level (Evans, 2005). Another interesting argument made by Ashkanasy,
Windsor, and Trevino (2006), is that managers with low cognitive moral
development who expected that their organisation condoned unethical behaviour
made less ethical decisions, while managers with high cognitive moral development
became more ethical in their environment. However, Loescher (2004) found that the
impact of formal education on ethical maturity levels of African-American business
professionals is not always significant, but that other factors such as being a tenure
student and academic performance measured in terms of their grade point average
(GPA) can affect the individual’s moral development.
Following the classification methods of the three previous reviews (O’Fallon &
Butterfield, 2005; Loe et al., 2000; Ford & Richardson, 1994) the next individual
factor is a combination of factors such as education, job satisfaction, and work
experience. Overall, this category of factors was the seventh most researched factor
and the third most researched between 1996 and 2003, according to the reviews:
O’Fallon and Butterfield (2005), 41 studies; Loe et al. (2000), 16 studies; and Ford
Ethical decision making and health care managers | 53
and Richardson (1994), 23 studies. Again, the findings are mixed across the three
reviews. Jones and Gautschi (1988) discovered that masters-degree students were
less likely then bachelor-degree students to exhibit a loyalty response. Browning and
Zabriskie (1983) reported that managers with higher education were more likely to
judge gift giving as an unethical practice than managers with a lower education level.
On the other hand, McNichols and Zimmerer (1985), after surveying 1,178
undergraduate students in relation to 10 ethical scenarios, concluded that there were
no significant differences in relation to educational level (first-year students and
final-year students). Dadisho (2005) supported the idea that people with higher
education levels would score higher on moral development than less educated
people. More recent research on education as an influencing factor has revealed that
not only is there a significant difference between first-year and final-year students
but also that there could be an internal difference within first-year and final-year
cohorts (O’Leary & Pangemanan, 2007; Hall & Berardino, 2006). For instance, it has
been found that senior accounting students have performed significantly different
when asked to participate to a group decision-making simulation scenario than when
they were asked to make an individual choice (O’Leary & Pangemanan, 2007).
When part of a group, the outcome of senior accounting students dealing with ethical
conflict tended to be more moderated as a result of consensus; however, when they
were asked to make a decision individually in a similar situation, they were more
inclined to take the extremes options—unethical or ethical (O’Leary & Pangemanan,
2007). Another interesting finding is presented by Hall and Berardino (2006) who
suggest that young adults (first-year undergraduate students) are influenced by their
attitudes in the way that they perceive an ethical situation. In relation to professional
experience, on one hand, Kidwell, Stevens, and Bethke (1987) argued that the greater
Ethical decision making and health care managers | 54
the working experience, the higher the likelihood of ethical behaviour, and Weeks,
Moore, McKinney, and Longenecker (1999) discovered that individuals in the latter
stage of their careers were more inclined to make moral decisions. On the other hand,
Serwinek (1992) did not find significant correlation between years of professional
experience and ethical perception of 421 small-business staff surveyed. However,
Gunz and Gunz (2008) found that well trained and highly professional people find
ways to minimise perceived conflict between their profession and organisational
obligation, which results in a biased capacity to judge ethical situations.
3.3.3 The degree of a factor’s influence on ethical decision making: Organisational Factors
Organisational factors comprise all of those factors inherent to a particular enterprise
that are, in some degree, able to influence individual ethical decision making. The
most common organisational factors are: codes of ethics and codes of conduct,
rewards and sanctions, organisational climate and culture, industry type,
organisational size, referent groups, and training. Research interest in the impact that
codes of ethics or codes of conduct have on ethical decision making has been
increasing. Nine studies were recorded by Ford and Richardson (1994), which
increased to 17 in 2000 (Loe et al., 2000) and 20 in 2005 (O’Fallon & Butterfield,
2005). There is agreement across these three reviews that codes of ethics and codes
of conduct are influential factors in ethical decision making (O’Fallon & Butterfield,
2005; Loe et al., 2000; Ford & Richardson, 1994). Arguably, codes increase ethical
awareness in organisations and stimulate reporting of unethical behaviours (Barnett,
Cochrane & Taylor, 1993; Barnett, 1992). Peterson (2002) and Somers (2001)
argued that organisations that had a code of ethics acted more ethically than those
without them. Conversely, Murphy et al. (1992) concluded from surveying 149
Ethical decision making and health care managers | 55
companies that codes of ethics had made little contribution towards predicting ethical
behaviour. Recent papers have supported the fact that codes of ethics are important
in setting up guidelines to enhance managerial ethical decision making (Ingram,
LaForge & Schwepker, 2007; Rottig & Heischmidt, 2007; Coughlan, 2005; and
Frame & Williams, 2005). For example, Coughlan (2005) argued that codes of
conduct in most cases provided decision makers with a reasonable justification in
resolving an ethical dilemma. However, a word of caution comes from Frame and
Williams (2005), who iterate that codes are effective as long as they are reflecting the
current internal and external context. In their analysis of the code of ethics and
standards of practice of the American Counseling Association, they found that that
the code did not adequately address the demands of working with non-white, non-
western clients (Frame & Williams 2005).
The next organisational factor is rewards and sanctions. Interestingly, the number of
studies that have included this factor as influential in ethical decision making has
decreased in the past decade, from 15 studies in 2000 (Loe et al., 2000) to only eight
studies in 2005 (O’Fallon & Butterfield, 2005). From the last literature review
articles on ethical decision making included in this paper (O’Fallon & Butterfield,
2005), it has been reported that only one out of eight studies found no significant
relation between rewards and sanctions and ethical decision making. In particular,
rewarding unethical behaviour was more strongly correlated with engaging in
unethical behaviour than rewarding ethical behaviours was with acting ethically
(Baumhart, 1961). Furthermore, Tenbrunsel (1998) argued that individuals working
under higher incentive conditions are more likely to engage in unethical behaviours.
Conversely, Hunt, Kiecker, and Chomko (1990) have argued that neither reward nor
Ethical decision making and health care managers | 56
sanctions are strongly associated with acting socially responsible. More recently, Nill
and Schibrowsky (2005) discovered that perceived moral intensity is directly
influenced by rewards and sanctions, and also Watson and Berkley (2009) argued
that rewards and sanctions can moderate or influence personal values in relation to
assessing compliance between situational factors and unethical decisions.
Over the years, the focus on organisational climate and culture in relation to ethical
decision making has dramatically increased from one major study by Victor and
Cullen in 1988, reported by Ford and Richardson (1994); four studies reported by
Loe et al. (2000); and 16 studies reported by O’Fallon and Butterfield (2005). This
trend has been based on strong empirical findings (12 out 16 studies) that have
consistently reported a strong relationship between organisational climate or culture
and ethical decision making (O’Fallon & Butterfield, 2005). Victor and Cullen
(1988), using a three by three matrix of three ethical criteria (egoism, benevolence,
and principle) and three loci on analysis (individual, local, and cosmopolitan), have
argued that there are at least five organisational climates that are positively correlated
to ethical decision making. This position has been backed up by Bartels, Harrick,
Martell, and Strickland (1998). Surveying 1,078 human resource managers, they
found a statistically significant positive relation between the strengths of an
organisation’s ethical climate and its success in responding to ethical issues. On the
other hand, DeConinck and Lewis (1997) found that organisational climate was not
significant when tested as a predictor for managers’ intention to intervene in cases of
ethical and unethical sales force behaviours.
Ethical decision making and health care managers | 57
Recent literature not only supports the fact that organisational culture is a factor that
can strongly influence ethical decision making (Ampofo, 2005), but also provides a
number of strategies on how to manage an ethical culture such as: a) strengthening
the code of ethics, which it is important to embed into the organisational climate via
an effective communication process (Stevens, 2008), b) promoting positive ethical
behaviours (Ferrell, Fraedrich, & Ferrell, 2008), c) using positive reward
mechanisms supporting ethical behaviours (Bowen, 2004), and d) providing ethical
training (Sekerka, 2009).
Even though only one out of nine recent studies concluded that there was no
significant relation between industry type and ethical decision making (O’Fallon &
Butterfield, 2005), and one out of three previous studies (Ford & Richardson, 1994),
there is still not a clear indication of that relationship. This particular factor has not
been studied in depth, especially not by comparing different industry types in the
same study. Nevertheless, it has been argued that auditors, for example, have a
particular predisposition for economic and utilitarian principles in their decision-
making processes, characteristics that tend to be industry-based rather than
individual-based (Shafer, Morris, & Ketchand, 2001). This argument suggests that
the idea that different industries can have unique characteristics and principles in
ethical decision making, which ultimately have an impact on ethical decision
making, is still worth further exploration. However, recent research articles have
found that different industries might have significant differences when it comes
down to ethical decision making: a) in the information technology industry, great
attention is given to legal aspects and intellectual property is seen as a strong
contributor for a competitive advantage (McGowen, Stephens & Gruber 2007); b)
Ethical decision making and health care managers | 58
the health care industry is mostly driven by a coherent and logical ethical decision-
making solution (Victor, 2007); c) in the retail industry, friends’ opinions contributed
more to individual ethical decision making than a manager (Fraedrich & Lyer, 2008);
d) the psychology industry, due to a lack of clear direction from their code of ethics,
relies on three dimensions of ethical decision making: power, duration, and clarity of
termination (Barnett, Behnke, Rosenthal & Koocher, 2007); e) the hospitality
industry is characterised by the importance of the individual moral intensity (Ng,
White, Lee, & Moneta 2009); f) in the cable news networking and broadcasting
industry, the experience of the employees was important in making ethical decisions
(Boone & Macdonald 2009); g) in the financial industry, circumstances often
outweigh an individual’s good intention (Prentice, 2007), and h) bioscience
companies deal with ethical dilemmas by having different mechanisms based on the
nature of the ethical issues (Mackie, 2004).
Organisational size, like industry type, has been relatively neglected as a focus of
research in ethical decision making. Five out of seven studies have not found
significant correlations between organisational size and ethical decision making, and
the remaining two had mixed findings (O’Fallon & Butterfield, 2005). Chavez,
Wiggins, and Yolas (2001) reported a positive correlation between the company size
and ethical decision making, while Bartels et al. (1998) argued the opposite.
However, Rosen, Hall, and Stainer (2005) suggested that any size organisation can
be ethical as long as they have sustainable ethical policies in place and that they are
committed to them.
Ethical decision making and health care managers | 59
The final organisational factor is training. Oddly, it has not been given justice in the
past as either important or influential in ethical decision making; only one study was
recorded according to O’Fallon and Butterfield (2005). In a study carried out by
McKendall, DeMarr, and Jones-Rikkers (2002), ethical training courses were found
to be not significant in relation to ethical decision making, mostly due to the fact that
those courses were developed as part of ethical compliance programs rather than as
more discursive and insightful training experiences in themselves. In support of this
idea, Kavathatzopoulos (2003) argued that for business ethics education programs to
be able to positively contribute to ethical decision making, the critical factors for
acquiring ethical competencies have to be identified well in advance and acted upon.
From the results of three independent samples in Germany and the United States,
Rottig and Heischmidt (2007) argued that ethical training can be a successful tool to
minimise significant differences in approaching ethical decision making based on
cultural differences.
3.3.4 The degree of a factor’s influence on ethical decision making: External Factors
Lastly, there are those factors that belong neither to the individual nor to the
organisation, but which impact on the decision-making process from the outside.
These factors are referred to by researchers as external factors or the general
environment; they are seen as the background conditions in which the organisation
operates (Schermerhorn , 2005; Jirasek, 2003; Peer & Rakich, 1999; Zentner & Gelb,
1991). These external factors can be grouped into six main categories: political and
legal, economic, social and demographic, technological, environmental, and
competition (Schermerhorn, 2005; Jirasek, 2003; Peer & Rakich, 1999; Zentner &
Gelb, 1991).
Ethical decision making and health care managers | 60
Political and legal factors can influence ethical decision making in two different
ways: firstly, an individual’s political ideology may consciously or unconsciously
affect them when making a decision; secondly, the political philosophy followed by
the party or parties running the government can influence companies directly, in
terms of public policy, and indirectly through laws and government regulations
(Deshpande, 2009; McGowen, Stephens, & Gruber, 2007; Smith, Simpson & Huang,
2007; Schermerhorn, 2005). Economic factors such as inflation, interest rates,
unemployment, income levels, gross domestic product, and other related indicators
of the economic wealth of a nation can influence the decision maker (Schermerhorn,
2005; Jirasek, 2003; Peer & Rakich, 1999; Zentner & Gelb, 1991). Social and
demographic factors are the social values on issues such as human rights, trends on
education, employment, and morality (Patel & Schefer, 2009; Knapp & Vandecreek,
2007). Demographic factors are important as the different demographic composition
of a particular location may require the provision of different services and products
(Schermerhorn, 2005). Technological factors are based on the development and
availability of new technologies, including scientific advancement (Schermerhorn,
2005). Environmental factors incorporate all of the issues related to the natural
environment, including levels of public concern expressed through environmental
groups.
3.4 Summary of the literature review
In summary, the most salient point to make regarding 48 years of research into
factors influencing ethical decision making is about the quantity of these factors
available in the literature that have been found capable of influencing decision
Ethical decision making and health care managers | 61
makers. The fact that there are so many factors that have already being identified as
influential in the literature supports the initial claim of this paper for a taxonomic
framework capable of summarising them. This study acknowledges the great
contribution made by previous research in creating the current knowledge on ethical
decision making, and uses the output of this research as building blocks to achieving
greater outcomes. In order to explain the aim of this paper, an analogy for building a
car will be used. Most of the time, car manufacturers assemble parts that have been
developed and produced by different suppliers to produce the car. In the same way,
the current paper has successfully identified a large number of separate factors
(Table 3.2) that have been previously tested for their influence on ethical decision
making, and introduced them into the proposed taxonomic framework. For example,
some studies have tested the engine (cognitive moral development); some others, the
gear box (ethical training). Using our analogy, these studies are of limited value on
their own, but they can be seen more as a means to further and more complex
analysis, with the final aim being to build a high quality multidimensional framework
(car). The following section presents the taxonomic framework for factors
influencing managerial ethical decision making that has been proposed in this paper.
3.5 A taxonomy of factors influencing ethical decision making
From the review of the current literature it is clear that there is a large of number of
factors that have already been individually analysed and found capable to influence
ethical decision making (O’Fallon & Butterfield, 2005; Loe et al., 2000; Ford &
Richardson, 1994). However, what the current literature is lacking is a coherent
taxonomy that, by summarising all of these factors, can provide a better picture of
the most common influences on managerial ethical decision making in practice. As
Ethical decision making and health care managers | 62
the aim of this taxonomy is to combine a large number of factors that have been
tested almost individually as influential in managerial ethical decision making, it is
important to group all of these influencing factors into a number of categories that
can best capture their real nature and can be easily recognised and used in practice.
As previously discussed, the proposed taxonomy has four categories of factors:
ethical, individual, organisational, and external (Figure 3.1). Having now identified
and developed the four categories of influencing factors, the next step is to justify
each of the four components not individually but as part of the proposed taxonomic
framework for managerial ethical decision making.
Figure 3.1 Taxonomy of factors influencing managerial ethical decision making
This figure represents an evidence-based taxonomy of factors influencing ethical
decision making by combining a large number of factors into four categories: ethical,
individual, organisational, and external.
Ethical decision making and health care managers | 63
The central circle represents managerial ethical decision making (MEDM) based on
the combination of the four categories of factors. Its colours represent the degree of
influence that these four categories can have on ethical decision making. The circle’s
colour combination can vary based on the degree that the four categories of factors
play on individual managers. For example, the managerial ethical decision making
circle for a manager who is strongly influenced by deontology and ethical training
will be represented by a circle that is dark orange and blue.
The orange triangles represent the four schools of moral philosophy—ethical
factors—which are instrumental to ethical decision making. These four schools can
either individually, or in combination, influence ethical decision making to varying
degrees (graphically represented by convergent triangles that start separately and
converge in the middle).
3.5.1 First dimension the ethical factors
There is a very animated debate in ethics as to whether the focus should be on
matching the demand of particular situation to universal principles or whether the
goal ought to be to find the principles or approach appropriate for a particular
Ethical decision making and health care managers | 64
situation; in short, whether one subscribes to an absolutist or a pluralistic viewpoint
(Hinman, 2003; Ferrell et al, 2008). Both sides have strong supporting arguments.
An increased number of papers (six in Loe et al., 2000; 23 in O’Fallon & Butterfield,
2005; and three in the most recent literature) in the current literature on ethical
decision making is based on Kohlberg’s CMD model; for example, Rest (1979) and
Lind (1995). CMD is a theory that divides respondents into different categories (six
stages) based on their individual level of moral development (Kohlberg, 1979).
Typically, however, each respondent can belong to only one particular stage at any
given time, reflecting the absolutistic view. The problem with this absolute approach
to ethics is the underlying assumption that individuals fit perfectly into only one
stage at a time. In reality, it seems more plausible that individuals could belong to
different stages in different situations, or that even in the same situation their actions
could be the result of a combination of different stages used conjointly. In order to
reduce the likelihood of preconceived bias towards an absolutist approach, the
proposed framework of managerial ethical decision making has been developed in
such a way that it is flexible enough to capture a continuum of responses from
absolutism to pluralism.
In the framework (Figure 3.1), it is possible to see that the four schools of moral
philosophy are separated at the beginning, giving the opportunity to be chosen
individually (absolutism); they can also converge into the centre, giving the
opportunity to be chosen in combination with others (pluralism). Thus, if a manager
strongly belonged to only one school of moral philosophy, then they would mostly
adopt all of the principles and criteria from that particular approach in reaching an
ethical decision. On the other hand, if a manager used a more pluralistic approach to
Ethical decision making and health care managers | 65
ethics, then they would reach an ethical decision by using a mix of principles from
two or more schools of moral philosophy.
3.5.2 Second dimension: the individual factors
In relation to individual factors, an individual manager would be influenced, more or
less, by every factor included in this group; however, not every factor would
necessarily impact on the manager to the same degree. Therefore, providing a range
of choices to represent the factors in this group is vital. For that reason, the most
common individual influencing factors identified in the literature (O’Fallon &
Butterfield, 2005; Loe et al., 2000; Ford & Richardson, 1994), such as Kohlberg’s
CMD, age, gender, education, professional experience, ethical training, personal
values, and nationality, should be incorporated in the framework. What would
happen in practice at this level when a manager would be put in a situation of making
a decision? In answering this question it is important to divide the individual factors
Ethical decision making and health care managers | 66
into two main categories based on the nature of these factors: first the ones that are
from birth and the ones that are related to human development and interactions with
others. Initially, those individual factors related to birth (age, gender, and nationality)
would start to shape the EDM process, which would then be further shaped by those
individual factors related to human development and interactions with others
(religion, cognitive moral development, professional experience, ethical training and
training in general).
3.5.3 Third dimension: the organisational factors
As previously argued, a number of organisational factors can influence ethical
decision making in different ways (O’Fallon & Butterfield, 2005; Loe et al., 2000;
Ford & Richardson, 1994). Organisational culture, for example, influence decision
maker’s judgment by pushing particular values that have been formally or informally
shared within a particular organisation (Ampofo 2005). However, these
organisational values might also conflict with the ones that the individual would
usually hold and act upon outside of the organisation. For example, in researching
the problems emerging from the Bundaberg Hospital Commission of Inquiry, Casali
Ethical decision making and health care managers | 67
and Day (2010) found that both the values of the staff and the espoused values of the
organisation were similar and positive, whereas the values promoted by the
organisational culture in practice comprised bullying, fear, tokenistic consultation,
and power control (Casali & Day, 2010). As a consequence of this powerful
influence that organisational factors can have on managerial ethical decision making,
the main organisational factors have been identified and incorporated into the
managerial ethical decision making model. Once again, in order to reflect the real
preferences of the managers as much as possible, all of those factors have been
converted into independent items.
3.5.4 Fourth dimension: the external factors
In the same way, external factors, even though they do not influence ethical decision
making directly, play an indirect but important role in shaping ethical decision
making. For example, in the public health care sector, political factors such as
strategic direction can have a great deal of influence when making a decision. More
particularly, budget allocation in Australia is driven by government policy. Hospitals
will have more or less to play with depending on Treasury allocations. In addition to
Ethical decision making and health care managers | 68
this, it has been found that physicians and hospital employees with political
connections were significantly less ethical than other employees (Deshpand, 2009).
The social factor is another important external factor, which, by setting societal
standards, puts pressure on the overall performance of a business (Hagan & Moon,
2001). Competition can also put strong pressure on ethical decision making as the
increase of global competition has also increased the complexity of making
organisations commercially successful (Stainer, 2004). Similar to the other factors,
the main external factors have been converted into individual items, and tested
independently.
3.6 Conclusion
This paper has offered an evidence-based taxonomy based on more than 40 years of
research into factors influences ethical decision making. From the review of the
literature, 26 influencing factors (Table 3.2) have being identified and summarised
into four categories: ethical factors, individual factors, organisational factors, and
external factors (Figure 3.1). Each of the four categories of factors influencing
ethical decision making can influence managers. The main contribution of such an
evidence-based taxonomy is that it sets the foundation for further research on the
multidimensional aspects of ethical decision making and, more importantly, on what
really influences managers at work. This taxonomy not only collects a large number
of factors influencing ethical decision making, and allocates them into four mutually
exclusive and unambiguous categories that include all possible factors influencing
ethical decision making, but also describes the way in which these four categories
influence ethical decision making.
Ethical decision making and health care managers | 69
This study has its limitations—relying on secondary data being collected by three
reviews covering only certain academic journals, which may have resulted in other
influential factors being omitted from this framework. Also, another possible
limitation of this evidence-based taxonomy is that it provides a way to classify
factors influencing ethical decision making but it does not attempt to measure actual
behaviour. Nevertheless, the proposed evidence-based taxonomy provides a valuable
basis for the development of a multidimensional tool to assess factors influencing
ethical decision making. It allows researchers to create a more practical
multidimensional research tool to understand the weighting of importance that all of
these factors play on decision makers. In conclusion, the proposed taxonomy will
provide managers with a full view of what can influence them when they make
decisions, and eventually help them to make a more sound ethical choices, not only
because they are more aware of the possible influencing factors but also because they
can assess themselves against their personal attitude toward these factors.
Part 2 Pilot study
Developing and validating the Managerial Ethical Profile (MEP) scale, and
investigating the possible profiles arising from the newly developed scale.
Introduction
Part 1 highlighted the research problem as a lack of understanding about factors
influencing managerial ethical decision making in the health care industry (Chapter
2), and developed a taxonomy of influencing factors for managerial ethical decision
making (Chapter 3).
Ethical decision making and health care managers | 70
Part 2—Chapters 4 and 5—is more exploratory in nature. Chapter 4 reports on the
initial validation of the discriminant capacity of the MEP scale by using a pilot study
comprising two very different, purpose-selected samples—academics and students
(n=41), and small-business managers (n=41). The purpose of Chapter 5 is to explore
clusters across the pilot study data and to categorise them as MEPs.
Chapter 4 aims to empirically test the initial validity of the MEP scale, especially
the ethical sub-scales (also referred to as criteria), by using the MEP scale on the two
samples. Significant differences were found between the two cohorts, suggesting that
the scale is working. Chapter 4 prompts the question: Can the MEP sub-scale be used
to profile individuals?
Chapter 5 analyses the results of using MEP sub-scales to profile individuals.
Hierarchical cluster analysis (HCA) was used, providing five significantly different
MEPs. Chapter 5 prompts the question: Can the other influencing factors further
describe these five managerial ethical profiles?
Ethical decision making and health care managers | 71
The MEP subscales
Sub-scale number Name Code
Sub-scale 1 Economic Egoism SS1
Sub-scale 2 Reputational Egoism SS2
Sub-scale 3 Act Utilitarian SS3
Sub-scale 4 Rule Utilitarian SS4
Sub-scale 5 Self Virtue SS5
Sub-scale 6 Others Virtue SS6
Sub-scale 7 Act Deontology SS7
Sub-scale 8 Rule Deontology SS8
Preamble
Part 2 presents the initial development and validation of the MEP scale, which will
be further discussed in Part 3, by using the results from the main study (n= 441
usable questionnaires) (Appendix 1). Developing a new scale is a long and complex
process, which requires years of research and adjustments, and some time redefining
individual items and entire sub-scales. Although Chapter 6, will present the full
discussion about the development of the MEP scale, Part 2 provides a short
discussion as it is based on the results from the pilot study, which applied the MEP
scale to two samples. The MEP scale has been designed in a deductive way, and
therefore each item has been developed to be exclusively part of one of the eight
ethical sub-scales rather than developing a pool of items and subsequently
discovering factors by using exploratory factor analysis (DeVellis, 2003). Despite a
full discussion on items development included in Chapter 6, it is necessary to
Ethical decision making and health care managers | 72
mention that all of the items have been developed in accordance with the current
literature and that content validity was achieved by interviewing 14 experts in the
field of ethics, philosophy, and religion. Once the items and appropriate sub-scales
were developed, the next step was to see the MEP scale in action and therefore the
need for a pilot study emerged. The first pilot study was performed on academics and
students (n=41) based on the fact that academics and students, while apparently
different, share a number of similarities, especially in terms of their ability to
critically evaluate information and knowledge. In contrast, the second sample—
small-business managers—was chosen to be significantly different from the first as it
relied on experiences rather than formal education.
In order to initially measure the psychometric capabilities, or what is also called the
internal consistency of the MEP scale, Cronbach’s Alpha test was performed on each
of the eight ethical sub-scales (Table 3.3).
Table 3.3 Results of Cronbach Alpha analysis
Sub-scale Alpha Sub-scale Alpha
SS1–Economic egoism 0.799 SS5–Self virtue 0.843
SS2–Reputational egoism 0.691 SS6–Others virtue 0.723
SS3–Act utilitarian 0.876 SS7–Act deontology 0.463
SS4–Rule utilitarian 0.663 SS8–Rule deontology 0.780
As a rule of thumb, every sub-scale around .7 is seen as moderately reliable
(DeVellis, 2003). There are five out of the eight sub-scales that would fit into this
category: SS1–Economic egoism, SS2–Reputational egoism, SS4–Rule utilitarian,
SS6–Others virtue, and SS8–Rule deontology. There are two sub-scales that have
Ethical decision making and health care managers | 73
performed better (SS5–Self virtue: 0.843 and SS3–Act utilitarian: 0.876), and only
one that has not performed as well (Act deontology 0.463). Despite the fact that act
deontology sub-scale has not yielded a good result of internal consistency, it was
decided to keep it as it is and to move to the next stage (larger sample). This decision
was based on two reasons:
1. When using exploratory factor analysis with the six items representing
Deontology, the items have split into the two expected sub-scales (Act
deontology and Rule deontology).
2. The experts’ opinions were strong in supporting the appropriateness
of maintaining two sub-scales for Deontology (act and rule).
The importance of Part 2 is to initially test the newly developed MEP scale with two
pilot studies for two main reasons:
1. To initially test the psychometric capability of the MEP scale in
discriminating between different respondents. This aim, achieved in
Chapter 4 by using the MEP scale on two a priori different cohorts
(academics and students, and small business managers), has identified
significant differences in their responses, suggesting that the MEP scale
has the capacity to discriminate and that it can therefore be used as an
instrument to classify respondents into groups.
2. To look at the preliminary results of a cluster analysis based on the MEP
scale results and possible clusters (profiles). Chapter 5 reports the
findings of HCA (methodology adapted due to the small sample size,
n=41) performed on the results from the two pilot studies.
Ethical decision making and health care managers | 74
Chapter 4
A quest for ethical decision making: Searching
for the holy grail and finding the sacred trinity
in ethical decision making by managers
4.1 Abstract
The study aim was to initially identify what ethical frameworks managers use when
making decisions and whether they differ from those used by the wider community.
A questionnaire was distributed to a number of small business managers, university
academics, and university students. Results show that that there are some statistically
significant differences between the ethical decision-making profile of business and
non-business decision makers; however, somewhat surprisingly, concern for the
bottom line is not seen by small-business managers as the most important criterion in
managerial decision making to the exclusion of other more ethical criteria.
4.2 Introduction
In recent years, the public’s attention has been captured by reports of organisational
actions leading to catastrophic consequences for stakeholders. The bankruptcies of
Enron Corp. and Tyco International Ltd.—which stripped thousands of people of
their jobs, pension funds, and dignity—are only two of many recent examples where
the actions of managers have been viewed as patently wrong or unethical by society,
but right and justifiable by the perpetrators. When interviewed, many of those
accused of wrongdoing have passionately argued that they have always acted in the
Ethical decision making and health care managers | 75
best interests of their shareholders, making decisions that maximised profits in order
to fulfil their duty of care as managers (Sims & Brinkmann, 2003). In practice, then,
definitions of what constitutes ethical or unethical decisions are contested, changing
dramatically with the points of view of the various stakeholders (Johnson, 2007;
Sims & Brinkmann, 2003). One possible step towards preventing such future
corporate disasters would be to be able to anticipate and clarify these divergent
points of view within an organisation, assessing which will further organisational
goals and which might undermine those goals. As a step in the direction of
developing a potential tool to accomplish this task, this paper attempts to answer the
question: what ethical frameworks do managers use in making decisions?
It is well established that a number of different ethical frameworks may be applied
when making decisions, each used either in its own right or combined in a pluralistic
approach (Hinman, 2003). Almost all business and management ethics textbooks, for
example, begin with a chapter explaining the different ethical frameworks that aim to
provide a definition of what constitutes a right action. Collectively, these have been
variously described as ethical reasoning (Grace & Cohen, 1995); moral philosophies
(Ferrell, Fraedrich, & Ferrell, 2006); welfare, rights, and justice (Boatright, 2007);
ethical and economic theoretical grounding (Collins-Chobanian, 2004), and ethical
theories (Fisher & Lovell, 2003). What has not been as well established is how and to
what extent managers draw on these ethical frameworks in the daily fulfilment of
their managerial duties, and whether doing so contributes either to unity of
organisational purpose or congruence with community standards.
Ethical decision making and health care managers | 76
Part of the problem may be due to what appears to be a divergence between the
normative models of decision making and everyday practices. In business and
management training literature, there are many models of decision-making processes
available; however, they do share some common assumptions. For example, Guy
(1990), in her assessment of ethical decision making in everyday work situations,
observed that ‘in the Western world, we applaud rationality’ (p. 28). Typically, a
rational decision is ‘one that occurs in ordered steps and maximises a value, whether
it is honesty, efficiency, reliability, controllability, marketability, or any of many
values’ (p. 28). In practice, these values may clash, but a step-by-step approach
allows the rational decision maker to revisit an issue until the relevant values are
maximised. Many issues are also multidimensional, requiring several iterations of the
steps in the decision-making process. Guy warns, however, that these ideal models
make many assumptions. They assume, for example, consistency in values and
tastes, and the availability of time and energy to thoroughly investigate problems,
both of which are not always present in real-world applications. Drawing on the
work of Nobel Prize winner, Herbert Simon, she suggests ‘the evidence is
overwhelming that the theoretical model of rational decision making does not reflect
actual decision making process’ (p. 31).
Given that decision making in practice diverges from the ideal type, will
commitment to ethical frameworks restore organisational unity of purpose? It has
become common to refer to ethics as a sine qua non of business. Nonetheless, the
introduction of ethics into an organisation, if not well managed and well understood,
could in fact aggravate current organisational problems (Johnson, 2007). This could
happen, for example, when different individuals in the same organisation judge the
Ethical decision making and health care managers | 77
ethics of an action or situation by using radically different ethical frameworks,
effectively increasing the level of conflict between staff. The issue is not whether
managers take different approaches to ethical issues, but whether these different
approaches, and their impact on decision-making processes, are clearly understood
within the organisation. Arguably, the ability to outline the ethical frameworks drawn
on by individual managers as criteria for their ethical decision making could be an
important step towards achieving transparency and accountability within
organisations. It could bring more predictability into an organisation’s ethical
performance without detracting from diversity.
In management, as in other professions, discussions of the ethical frameworks
underpinning decisions have focused primarily on three major approaches: the ethics
of consequences (ethical egoism and utilitarianism), duties (Kantianism and
principlism), and character (virtue). In recent times, additional interest has been
directed to more contextual and relationship-based accounts of ethics, derived mainly
from feminist ethics (ethics of care and applied ethics). It is clear that these newer
frameworks require a different approach to decision making than the traditional
ethical frameworks, which Walker (1998) characterised as ‘theoretical-juridical’.
They are concerned with deductively applying codifiable sets of moral formulas in
ways that provide universal answers to particular problems. Walker identifies the
newer frameworks as ‘expressive-collaborative’: seeing moral life as a continuing
negotiation among people, determined not only by seeking shared moral values, but
also by developing and sustaining committed relationships. Like many proponents of
virtue ethics, those taking an ethics-of-care approach often downplay the role of
universal principles in decision making, instead drawing attention to the capacity of
Ethical decision making and health care managers | 78
persons to express compassion, care, or kindness as ethically important. One
approach often taken, and one accepted in the present study, is to include the ethics-
of-care approach within virtue ethics (Halwani, 2003). An ethics-of-care approach
also gives more prominence to the role of emotions in ethics (Halwani, 2003).
Perhaps understandably, then, for this reason, it has to this point in time had less
influence on managerial ethics, which, as noted, remains committed to ideals of
rational decision making.
Can the influence of these major ethical frameworks be detected at all in the decision
making of managers? To answer this question, a questionnaire was distributed to a
group of small business managers and compared with results obtained from a group
of university academics and students.
4.3 The study
The number of studies on ethical decision making has dramatically increased in the
past 40 years, with at least three major studies reviewing the literature on ethical
decision making from 1972 to 2003. Interestingly, the three studies came to a
common conclusion (Ford & Richardson, 1994; Loe et al., 2000; O'Fallon &
Butterfield, 2005). The latest paper, written by O’Fallon and Butterfield (2005),
reviewed the empirical literature on ethical decision making—from the most
prominent academic journals—between 1996 and 2003, and concluded that 174
studies had been carried out on this important topic during that period, many more
than in previous years. What is interesting is that none of these studies were able to
conclude that they had found the ‘Holy Grail’ of ethical decision making; they all
concluded that there is a need for further research to be done in this area. This would
Ethical decision making and health care managers | 79
seem to confirm that, in practice, there is not one universal definition of what is right
(the Holy Grail), but rather a few major ethical frameworks. In particular, there are
three major views of ethical decision making, which might be referred to as the
‘sacred trinity’: an ethic of consequences, an ethic of duty, and an ethic of virtue. In
the business ethics literature, these are also sometimes referred to as the three
constituent elements of ethical decision making: outcomes/consequences,
process/duty, and the individual/decision-maker character (Ferrell et al., 2005;
Hosmer, 2006). Do managers of small businesses use these ethical frameworks when
making decisions, or are they more likely to give prominence to economic, rather
than ethical, considerations in comparison to a section of the non-business
population?
4.4 Hypotheses
To answer this question, the pilot study will test two main hypotheses; first—
Hypothesis 1 (H1)— business managers are more drawn to ethical frameworks that
prioritise economic goals and, second—Hypothesis 2 (H2)— the ethical criteria they
use differ from the non-business population.
In the absence of any similar previous studies that would have investigated
managerial ethical decision making as an independent variable and the
operationalised principles from the schools of moral philosophy as the dependent
variables, the general conviction that, in business, the most important factor is the
pursuit of the bottom line (profit) has been adopted and implemented in the first
hypothesis. This idea was published by Friedman (1970) in the New York Times:
Ethical decision making and health care managers | 80
In a free-enterprise, private-property system, a corporate executive is an
employee of the owners of the business. He has direct responsibility to his
employers. That responsibility is to conduct the business in accordance with
their desires, which generally will be to make as much money as possible while
conforming to the basic rules of the society, both those embodied in law and
those embodied in ethical custom. Of course, in some cases his employers may
have a different objective. (p. 1)
In addition to Friedman’s statement, a Dallas Times Herald survey showed that 75%
of respondents believed that business people would bend the rules for success
(Axline, 1990), and a survey on excellence in journalism has shown that,
increasingly, concerns have been raised in relation to the trade of pressuring for the
bottom line against good coverage of the facts (Kohut, 2004).
It would be expected, then, that both the criteria belonging to egoism—SS1
economic egoism, in particular, and SS2 reputational egoism—would score higher
than any other criteria by the small-business managers.
4.4.1 Hypothesis one (H1)
Managers prefer an outcome-based ethical framework because it is the one
dimension that deals directly with economical return and self advantage.
To put the ethical decision making of business managers further into context, it is
important to ascertain whether there are significant differences between respondent’s
ethical preferences based on individual factors, including their profession. Over the
past 20 years, many studies have been conducted on the degree of impact that
Ethical decision making and health care managers | 81
different factors would have on ethical decision making. Professional experience and
industry type have been tested in different studies, producing mixed results (O'Fallon
& Butterfield, 2005). Nevertheless, although the results of research in this area are
ambiguous and sometimes contradictory, it is clear that there are some significant
differences in relation to ethical decision making based on profession. For example,
Sparks and Hunt (1998), found that professionals are more ethically sensitive than
students; while, on the other hand, Cohen, Pant, and Sharp (2001), did not discover
any significant differences between students and professionals.
In this study, responses from the small-business managers will be compared to
academics and students in relation to their performance against the eight ethical
criteria, in order to test the following hypothesis.
4.4.2 Hypothesis two (H2)
The ethical criteria that are of highest importance to managers of small- to medium-
sized businesses will differ from those of academics and students.
4.5 Measure
The data used for this research was taken from the developmental stage of a larger
project that profiles the influence of ethical frameworks and other external factors on
the decision making of individual managers. To test the hypotheses for the present
study, a questionnaire consisting of 24 items was used (Appendix 1). To cover the
three ethical approaches, discussed in section 4.3—outcomes/consequences,
process/duty, and the individual/decision-maker character—six items (statements)
were developed for ethical egoism, utilitarianism, deontology and virtue ethics.
Ethical egoism and utilitarianism constitute the two major forms of consequentialist
Ethical decision making and health care managers | 82
theory. Ethical egoism is the view that, when considering outcomes, people ought to
act out of self interest. If everyone acts in this way, it is argued, interests will
ultimately balance out. Utilitarians, on the other hand, seek to make decisions that
create the greatest good for the greatest number—good being defined in a variety of
ways from maximising pleasure and minimising pain, through to maximising
interests (Marshall, 2005). Within utilitarianism, there is also a distinction between
‘act utilitarianism’, wherein one seeks to judge the greatest good with respect to each
act, and ‘rule utilitarianism’, which seeks to follow rules that maximise the greatest
good for the greatest number (Hollingsworth, Hall, & Trinkaus, 1991). Deontology
or duty-based ethics does not make the consideration of consequences the primary
determinant of ethical deliberation (Micewski & Troy, 2007). Instead, deontologists
argue that there are certain duties incumbent on us all. Similar to utilitarianism,
deontology has two main interpretations of what is right or wrong based on either the
moral rules or on the nature of the act itself. According to ‘rule deontology’, a
decision is ethical as long as it has conformed to general moral principles, such as the
Kant’s categorical imperative: ‘Act as if the maxim of thy action were to become by
thy will a universal law of nature’ (as cited in Ferrell et al., 2005, p. 101) or the
golden rule: ‘do unto others as you would have them do unto you’ (as cited in Ferrell
et al., 2005, p. 101). Act deontology, instead of using predefined principles, promotes
the use of equity, fairness, and impartiality in making a decision applied to particular
acts. As distinct from the first two major approaches, which focus on acts and rules,
virtue ethics focuses on character. Virtue ethics gives more consideration to the
impact of choices on character and relationships (Van Hooft, 2005).
Ethical decision making and health care managers | 83
Content and construct validity have been tested in relation to the statements
representing these different dimensions of ethical decision making. Content validity
was tested by converting the main ideas of the different schools of moral philosophy,
as exemplified in the current literature, into more operational statements. In relation
to content validity, 14 experts in the field of ethics, philosophy, and theology from
Universities in South-East Queensland (Australia) were interviewed using semi-
structured interviews (De Vaus, 2002). Each statement was shown to the experts, and
they were asked to comment on the extent to which each of statements was
representative of the respective schools of moral philosophy. Most of the respondents
agreed on the representativeness of the consequence-based statements in relation to
egoism and utilitarianism. With respect to the statements about duty-based ethics,
there was general feedback that the six initial statements developed were too specific
(freedom of conscience, freedom of consent, freedom of speech, and due process),
and they did not adequately reflect general aspects of that particular ethical
framework such as the Golden Rule. Also, due to the fact that it is not as widely used
as the previous ethical frameworks, there was less agreement about the statements
reflecting the virtue-based approach. Some experts agreed that the statements were
quite representative of virtue ethics, while some others, with perhaps more expertise
in this particular area of moral philosophy, raised some concerns about the fact that
virtues are characteristics that are embedded in the character of decision makers and
not simply in what they do. For example the statement: ‘I make sure that honesty is
paramount in my decision making process’, was changed to ‘I am an honest person
and therefore I make only honest choices’. The statements were modified and
implemented in the final version of the questionnaire (Appendix 1), based on the
variety of concerns expressed by the experts interviewed.
Ethical decision making and health care managers | 84
4.6 Sample
As mentioned in section 4.5, the data used for this study was preliminary data that is
part of a larger study aimed at developing profiles of managers’ ethical decision
making (Appendix 1 -The MEP questionnaire). Initially, 82 people responded to the
questionnaire. The questionnaire was administered to two different samples—
academics and students (n=41) and small-business managers (n=41) on two
occasions.
From the first sample (academics and students), 18 academics were selected from
different faculties and universities and asked to answer the questionnaire. Sixty
second-year nursing students were asked to fill in the questionnaire, 23 of whom
returned it: a 38% response rate. On the other hand, a group of 79 small-business
managers who attended a monthly business breakfast organised by a regional
Business Centre Enterprise (not-for-profit organisation) were asked to fill in the MEP
questionnaire. Forty-three questionnaires were returned; however, only 41 were
completed in full: a 52% response rate.
4.7 Results empirical analysis
To test the two hypotheses, and to examine in more detail the relationship between
the variables of the eight ethical sub-scales, an analysis of variance (ANOVA) was
performed. Estimated marginal means were performed by using the computed results
of the eight ethical sub-scales (see Table 4.1) and compared based on the two groups
of respondents (small- and medium-sized-business managers, and academics and
students). Graphical representation of results of the estimated marginal means is
presented below (see Graph 4.1). The graph shows the mean results based on the 5-
Ethical decision making and health care managers | 85
likart scale (Y axis) of the two cohorts of respondents in relation to the different
ethical criteria (X axis).
Looking first at the graph, with respect to Hypothesis 1 (managers prefer an
outcome-based ethical framework because it is the one dimension that deals directly
with economic return and self advantage), it is clear that ethical sub-scales SS1, SS2,
and SS3 have been scored lower than the other five sub-scales by the small-business
managers. As previously discussed, sub-scale SS1 is focused on economical return,
sub-scale SS2 on organisational reputation, and sub-scale SS3 on act utilitarian. Even
though, graphically, it might look as though those three sub-scales are considerably
less important than the others, in reality they are not.
Table 4.1 Mean differences between small-business managers, and academics and student in relation to the eight ethical sub-scales
Source developed for this study by using SPSS version 15
Looking at the mathematical results behind this graph (see Table 4.1), it is possible
to see that these three sub-scales have mean scores just below 2— which in the MEP
scale is ‘very important’—and the other five factors are just below 1.5, ranking them
closer to 1—‘extremely important’. Nevertheless, in relation to the H1, economic
return is clearly not the most important factor in managerial decision making and, in
Ethical decision making and health care managers | 86
fact, it has been the lowest mean over the eight sub-scales for both samples (see
Table 4.2).
In conclusion, it is suggested that small-business managers did consider the bottom
line to be the most important factor in their decision-making processes, a finding that
disproves H1. This result could suggest that managers, when assessing different
options, would not seek the highest economical return without considering other
ethical criteria, derived from their personal values or common ethical frameworks.
Graph 4.1 Estimated marginal means
Turning to Hypothesis 2—that the ethical criteria that are of highest importance to
managers of small- to medium-sized businesses will differ from those of academics
and students—Graph 4.2 indicates that there were statistically significant differences
between the two samples in relation to the perceived importance of each of the eight
ethical criteria to the respondent’s decision making-process. The data confirms that
the non-business sample shows relatively little concern for economic factors in
ethical decision making compared to those involved in business. However, it is also
Ethical decision making and health care managers | 87
clear that the small-business managers’ concern for the bottom line is not to the
exclusion of other ethical criteria.
These differences are further confirmed by the results in Table 4.2, which were
generated using ANOVA (repeated measure of variance) and tested at 95% of
significance level; therefore, only the results with .05 and below are significant (see
results with the * symbols in Table 4.2).
Ethical decision making and health care managers | 88
Table 4.2 Estimated marginal means for ethical decision making
Group (I) ethics
(J) ethics
Mean difference (I-J)
Std. error
Sig. (a)
Group (I) ethics
(J) ethics
Mean difference (I-J)
Std. error
Sig. (a)
1.00 students and academics
SS1 Ethical Egoism
SS 2 .402 (*) .092
.001 2.00 small business managers
SS1 Ethical Egoism
SS 2 .079 .092
1.000
SS 3 .431 (*) .131
.041 SS 3 .043 .131
1.000
SS 4 .756 (*) .122
.000 SS 4 .474 (*) .122
.006
SS 5 .549 .175
.066 SS 5 .421 .175
.410
SS 6 .726 (*) .140
.000 SS 6 .494 (*) .140
.020
SS 7 .854 (*) .140
.000 SS 7 .360 .140
.289
SS 8 .866 (*) .139
.000 SS 8 .482 .139
.023
SS 2 Reputat- ional Egoism
SS 1 -.402 (*) .092
.001 SS 2 Reputat- ional Egoism
SS 1 -.079 .092
1.000
SS 3 .028 .108
1.000
SS 3 -.037 .108
1.000
SS 4 .354 (*) .109
.046 SS 4 .394 (*) .109
.014
SS 5 .146 .146
1.000
SS 5 .341 .146
.460
SS 6 .323 .115
.157 SS 6 .415 (*) .115
.014
SS 7 .451 .118
.007 SS 7 .280 .118
.424
SS 8 .463 (*) .120
.006 SS 8 .402 (*) .120
.034
SS 3 Act Utilitarianism
SS 1 -.431 (*) .131
.041 SS 3 Act Utilitarianism
SS 1 -.043 .131
1..000
SS 2 -.028 .108
1.000
SS 2 .037 .108
1.000
SS 4 .325 .103
.063 SS 4 .431 (*) .103
.002
SS 5 .118 .127
1.000
SS 5 .378 .127
.099
SS 6 .295 .100
.112 SS 6 .451 (*) .100
.001
SS 7 .423 (*) .094
.001 SS 7 .317 (*) .094
.033
SS 8 .435 (*) .110
.005 SS 8 .439 (*) .110
.004
SS 4 Rule Utilitarian-ism
SS 1 -.756 (*) .122
.000 SS 4 Rule Utilitarianism
SS 1 -.474 (*) .122
.006
SS 2 -.354 (*) .109
.046 SS 2 -.394 (*) .109
.014
SS 3 -.325 .103
.063 SS 3 -.431 (*) .103
.002
SS 5 -.207 .159
.998 SS 5 -.053 .159
1.000
SS 6 -.030 .100
1.000
SS 6 .020 .100
1.000
SS 7 .098 .104
1.000
SS 7 -.114 .104
1.000
SS 8 .110 .116
1.000
SS 8 .008 .116
1.000
SS 5 Virtue of Self
SS 1 -.549 .175
.066 SS 5 Virtue of Self
SS 1 -.421 .175
.410
SS 2 -.146 .146
1.000
SS 2 -.341 1.46
.460
SS 3 -.118 .127
1.000
SS 3 -.378 .127
.099
SS 4 .207 .159
.998 SS 4 .053 .159
1.000
SS 6 .177 .11 .969 SS 6 .073 .11 1.00
Ethical decision making and health care managers | 89
1 1 0 SS 7 .305 .11
8 .281 SS 7 -.061 .11
8 1.000
SS 8 .317 .120
.247 SS 8 .061 .120
1.000
SS 6 Virtue of Others
SS 1 -.726 (*) .140
.000 SS 6 Virtue of Others
SS 1 -.494 (*) .140
.020
SS 2 -.323 .115
.157 SS 2 -.415 (*) .115
.014
SS 3 -.295 .100
.112 SS 3 -.451 (*) .100
.001
SS 4 .030 .100
1.000
SS 4 -.020 .100
1.000
SS 5 -.177 .111
.969 SS 5 -.073 .111
1.000
SS 7 .128 .079
.962 SS 7 -.134 .079
.939
SS 8 .140 .098
.991 SS 8 -.012 .098
1.000
SS 7 Act Deontology
SS 1 -.854 (*) .140
.000 SS 7 Act Deontology
SS 1 -.360 .140
.289
SS 2 -.451 (*) .118
.007 SS 2 -.280 .118
.424
SS 3 -.423 (*) .094
.001 SS 3 -.317 (*) .094
.033
SS 4 -.098 .104
1.000
SS 4 .114 .104
1.000
SS 5 -.305 .118
.281 SS 5 .061 .118
1.000
SS 6 -.128 .079
.962 SS 6 .134 .079
.939
SS 8 .012 .093
1.000
SS 8 .122 .093
.998
SS 8 Rule Deontology
SS 1 -.866 (*) .139
.000 SS 8 Rule Deontology
SS 1 -.482 (*) .139
.023
SS 2 -.463 (*) .120
.006 SS 2 -.402 (*) .120
.034
SS 3 -.435 (*) .110
.005 SS 3 -.439 (*) .110
.004
SS 4 -.110 .116
1.000
SS 4 -.008 .116
1.000
SS 5 -.317 .120
.247 SS 5 -.061 .120
1.000
SS 6 -.140 .098
.991 SS 6 .012 .98 1.000
SS 7 -.012 .093
1.000
SS 7 -.122 .093
.998
Source: based on the results from the small-business managers and academics and students
Each cell in Table 4.2 describes the extent to which responses by the respective
samples to each individual criteria (I ethics) were significantly different (Sig. a) to
the other ethical criteria (J Ethics) surveyed. Confirming H2, the top cells for each
sample reveal that there was a statistically significant difference in their views of the
first ethical criteria, which reflects concerns for economic factors. Academics and
students have rated ethical criteria 1 (SS1 economic egoism) significantly lower than
Ethical decision making and health care managers | 90
almost every other criteria except character (SS5 self virtue) (see Table 4.2). On the
other hand, small-business managers rated the same criteria equally with SS2
(reputational egoism) and SS3 (act utilitarianism) and not significantly different from
SS5 (self virtue) and SS8 (rule deontology). The second difference lies in the level of
importance that the two samples have given to the eight ethical sub-scales (see Table
4.1). Even though both samples rated SS1 the lowest of all, small-business managers
still rated it as very important, while academics and students rated it as important.
Conversely, academics and students gave a higher rating to SS8 (rule deontology)
than small-business manager.
4.8 Conclusion
In conclusion, this chapter argues that, according to the literature, people use
different ethical criteria in their decision-making process, not exclusively from only
one school of moral philosophy (Holy Grail) but from the different dimensions of
ethical decision making (sacred trinity). There were some statistically significant
differences in terms of the degree of importance given to eight ethical criteria derived
from the three major ethical frameworks between two cohorts of respondents
(academics and students, and small-business managers). One interpretation of the
results could be that academics and students consider economic factors (SS1
economic egoism) only after first applying all of the other ethical criteria; that is,
principles of justice and individual rights should always come first, regardless of the
economic cost. On the other hand, it could be argued, on the basis of these results,
that small-business managers tend to first trust their own acquired sense of virtue;
that is, their gut feelings and taste for good business and character, based on good
Ethical decision making and health care managers | 91
habits acquired through practical experience. What is also interesting, from the point
of view of this study, is the compatibility of the results, from both the academics and
students and from the small-business managers, with the first three dimensions of so-
called corporate social responsibility. (It has been argued that organisations have four
responsibilities: economic, legal, ethical, and philanthropic (Carroll, 1991; Ferrell,
Fraedrich & Ferrell, 2005). Both cohorts have emphasised that economic returns are
important, as long as they are consistent with one’s own sense of virtue and are
reached while respecting other people’s rights.
Though this study has been limited in scope, and the statistical results are based on a
relatively small number of cases (n=82), the results have nevertheless shown
statistically significant differences in the way in which small-business managers
draw on ethical criteria for making decisions as compared to a non-business cohort.
Although the present study compared only small-business managers to academics
and students, and no individuals from a larger corporation were included in the study,
from these early indications, it is clear that reliable scales may be further developed
to obtain data on the ethical frameworks used by managers in a wider variety of
settings, including larger corporations. There have also been different studies that
have concluded that entrepreneurs or small-business managers are more value driven
than people working for larger corporations (Robinson, Davidsson, Van Der Mescht,
& Court, 2007). Using the scales developed in this study, it will be possible to extend
research into these promising areas.
Ethical decision making and health care managers | 92
Chapter 5 Creating managerial ethical profiles:
An exploratory cluster analysis
5.1 Abstract
This study profiles managers according to the ethical criteria that they bring to their
managerial decision making. Profiling was based on exploratory cluster analysis of
the responses of two cohorts: academics and students, and small-business managers,
to a multidimensional questionnaire. The data was collected through a self-reporting
survey (n=82) administered to the two cohorts. An agglomerative HCA was then
performed separately on the two groups’ results based on the eight ethical sub-scales
from the MEP scale. From the given data, groups were clustered using two methods:
between-groups linkage and squared binary Euclidean distance measures. For the
two cohorts, the optimal number of clusters for the given data set was determined to
be five for one and four for the other. Four clusters were common to both cohorts.
The study concludes that a cluster analysis is a useful method for finding the natural
grouping of not well understood influences of ethical principles in decision making,
and their representativeness of common practice.
5.2 Introduction
With the aim of being able to predict future behaviour, researchers and practitioners
have sought to classify people according to their particular personality traits since
almost the beginning of behavioural science. Profiling is a process of grouping
observed physical, social, or psychological differences in individuals into a series of
Ethical decision making and health care managers | 93
types, the behaviour of which will be more or less predictable (Dictionary.com,
2010). One of the first recorded attempts at profiling was by the Greek doctor
Hippocrates (c. 460–370 BCE), who developed four profiles based on four factors,
which he called ‘humours’ (fluids). The four humours were blood, yellow bile, black
bile, and phlegm (Kretschmer, 1925). Hippocrates argued that a person is healthy
when the four humours are in balance and that all diseases and disabilities are the
result of having either too much or too little of one or more of these humours.
Figure 5.1 The four temperaments: phlegmaticus, cholericus, sanguineus, melancholicus
Source: Lavater, (1775)
Ethical decision making and health care managers | 94
According to Hippocrates, four profiles or temperaments were linked to the four
humours: sanguine, choleric, melancholic, and phlegmatic (Kretschmer, 1925). A
sanguine profile referred to a person with the temperament of blood, which was
usually associated with optimism, cheerfulness, confidence, popularity, and being
fun-loving. A choleric profile was associated with the yellow bile; the people in that
group were usually leaders, had high ambitions, were very energetic, and could
dominate people of other temperaments, especially phlegmatic types. A melancholic
profile, which was directly related to the black bile, was associated with kindness and
perfectionism. Last, the phlegmatic profile was related to phlegm. People in this
profile were viewed as self-content, kind, and shy.
This age-old urge to profile has not gone away. Donald Trump (2004), for example,
includes comments on the importance of understanding psychological traits in
making deals in his ‘how to get rich’ strategies. He argues that understanding the
psychology of people involved in his deals has contributed to his success as a
dealmaker (Trump, 2004). Another example on the importance of psychological
profiling in business is the notion that the potential degree of success in a particular
role can be linked to the possession of particular personality traits; for example,
extroverted, introverted, intuitive, emotive, rational, and judgmental. Thus, Briggs-
Myers et al. (1998) developed a tool to psychologically profile people according to a
number of personality traits. Another widely used profiling tool is the Defining Issue
Test (DIT) developed by Rest (1979; 1990), which is based on Kohlberg’s Cognitive
Moral Development theory (Kohlberg, 1969). This tool presents respondents with
different scenarios and asks them to choose from a number of courses of action,
profiling them based on their answers. However, concerns have been expressed about
Ethical decision making and health care managers | 95
how realistic it is to establish an individual’s normal profile by testing their responses
to extraordinary situations.
From the ancient past to the present, the need to understand human behaviour and
render it more predictable and manageable has fostered profiling. Observing the
number of scandals that have occurred over the past 10 years in the business arena, it
is not surprising that there should be some renewed interest in being able to
understand and predict the likelihood that individuals will engage in ethical or
unethical behaviours. While much of the focus on the ethical renewal of public- and
private-sector organisations has focused on institutionalising ethics through codes of
ethics and other ethics regimes, there clearly remains a need to better understand the
individual factors influencing managerial ethical decision making. Analysing
managers’ facial shapes, and character traits, or testing their responses to
extraordinary scenarios, however, are unlikely to yield practical insights.
When profiling, individuals are clustered into groups using various characteristics as
discriminatory factors. To be successful, these clusters should maximise differences
between the groups, while at the same time minimising internal differences within
the group. In the modern era, profiling has been used in a variety of ways; for
example, marketers profile prospective customers based on age, income, location,
and attraction to innovation (Maenpaa, 2006). Profiling is also applied in the criminal
justice system (Pollock, 2004). Using factors such as gender, ethnicity, race, age,
personal history, abusive childhood, peer pressure, and others factors, profiles are
created to identify the characteristics of the perpetrators of specific crimes (Pollock,
2004). Potential suspects are then identified on the basis of these profiles. However,
Ethical decision making and health care managers | 96
profiling in criminal justice is open to justifiable criticisms, not only on questions of
individual rights, but also in regard to issues such as the biasing of profiles through
prejudice and stereotyping, as well as the lack of theoretical and empirical support
for its reliability and usefulness in practice (Pollock, 2004). These misuses of
profiling in the criminal justice domain remind us that the possible predictive
capacity of profiling is always a matter of probability rather than certainty. It is
meant to discriminate between, not against, people. Profiling starts off as a facet of
analysis; that is, the aim of the profiling, in each case, is to identify some factors (or
dimensions) that can discriminate between people, and group them into more or less
homogenous clusters.
To respond to the current needs in the business environment, a new approach to
profiling is overdue—a more realistic and practical approach linked to what
managers are dealing with every day, and one that includes ethics. To further this
aim, Chapter 5 reviews and evaluates a number of tools measuring ethical decision
making in the current literature and then proposes a new method of profiling
managers, based on their ethical preferences. With this purpose in mind, this paper
seeks to answer the research question: can managers be profiled according to the
ethical frameworks that they bring to their managerial decision making? To develop
managerial ethical decision-making profiles, it is important to first identify the
factors that can best facilitate a clustering process based on ethical characteristics.
5.3 Literature review
Usually, when people talk about ethics, they wittingly, or unwittingly, refer to ethical
frameworks that reflect the schools of moral philosophy (Casali, 2008a; Ferrell,
Ethical decision making and health care managers | 97
Fraedrich, & Ferrell, 2008). In the area of ethical decision making, there has been a
significant increase, over time, in the amount of research on individual ethical
preferences, from virtually no studies before 1992 (Ford & Richardson, 1994) to 21
studies up to 1994 (Loe, Ferrell, & Mansfield, 2000), and 42 up to 2005 (O'Fallon &
Butterfield, 2005). It is not only the number of publications in the area of ethical
decision making that has increased over time, but also the kind of factors that have
been tested. As suggested by Casali (2008a) and Ferrell et al. (2008), the range of
influencing factors that has been tested over time can be summarised into four major
categories: ethical, individual, organisational, and external. As the focus of this study
is limited to the ethical factors, further analysis of the literature will concentrate on
those tools that have been used to measure the influence of ethics on managerial
decision makers. The most popular instruments used for this purpose are:
the Defining Issue Test (DIT) by Rest (1979; 1990)
the Managerial Judgment Test (MJT) by Lind (1978)
the Ethics Position Questionnaire (EPQ) by Forsyth (1980)
the Managerial Value Profile (MVP) by Sashkin, Rosenbach, & Sashkin (1997).
As indicated by Casali (2008a), all of these instruments have a number of limitations
such as:
All of them make a priori assumptions about to which and to how many
categories each respondent should be allocated.
For example, the DIT aims to allocate respondents into one of the six stages of moral
development created by Kohlberg (1969), and the MVP is focused on identifying
whether those respondents are either driven by utilitarian principles, individual rights
(deontology), or social justice perspectives. When using these tools, individuals are
Ethical decision making and health care managers | 98
grouped into predefined profiles.
They use scenarios that are purposely developed to embody an ethical dilemma.
Typically, respondents are provided fictitious situations and then asked what they
would do in each case. Often, they are provided with few options to choose from.
Each option is developed and presented with the assumption that if chosen, it will
indisputably suggest that the respondent belongs in one particular category rather
than the others. Once again, individuals are confronted with a forced-choice situation
but, more importantly, they are asked to think about how they would respond to
situations that they might have never encountered before, rather than asking them
how they already respond to more everyday ethical challenges.
Arguably, it would be better to profile managers according to their ethical
preferences. This would require adopting an a posteriori approach that creates the
clusters and profiles from the responses themselves. In the present study, for
example, respondents were not asked to simply place themselves into one of the four
schools of moral philosophy. Indeed, within each major school, respondents were
offered further options. So, for example, two main approaches to utilitarianism (act
and rule) were represented in the questionnaire. There was also a similar
dimensioning of the scales representing deontology, virtue ethics, and ethical egoism.
These scales were not used to directly represent types; rather, individual responses to
the multidimensional scales were subsequently analysed to determine whether there
was any statistically significant clustering of responses. These statistically significant
clusters were then interpreted by relating the data to recognisable behaviours.
Interestingly, none of the previous studies found that there is a universal ethical way
Ethical decision making and health care managers | 99
to make a decision; the one thing that they do agree on is that there is a need for
further research in this area. The variety of approaches taken also confirms that there
is not just one universal definition of ethics operating in the real world. Managers
draw on a number of different ethical frameworks in their decision making. These
differences can be explained by the fact that managers can, for example, look at
ethics in different ways (absolutism, relativism, and pluralism), or tend to favour one
of the major ethical frameworks (outcome-based, duty-based, and person-based).
Profiling managers based on their ethical preferences, then, requires a
multidimensional approach.
5.4 Method
To profile managerial ethical decision making, the MEP questionnaire was
administered to two different cohorts: one consisting of academics and students and
the other consisting of small-business managers.
5.5 Measure
The MEP questionnaire is a scale purposely developed to capture managerial ethical
preferences (Casali, 2007; 2009). The MEP scale consists of 52 items covering a
number of criteria that influence managerial decision making: ethical, individual,
organisational, and external (Casali, 2007; 2009). The first 24 items were purposely
developed as a multidimensional ethical scale representing different principles from
four major schools of moral philosophy: egoism, utilitarianism, virtue ethics and
deontology. The MEP scale comprises eight ethical sub-scales (Casali, 2007; 2009):
Ethical decision making and health care managers | 100
1. SS1–Economic egoism represents managerial self-interest, particularly in
terms of the role that economic outcomes such as profit and cost reduction
play in the managerial decision-making process.
2. SS2–Reputational egoism is a sub-scale that refers to managerial self-
interest pursued not in terms of economic outcomes, but by identifying
one’s organisation as an extension of one’s own interests. Therefore, the
manager would act to protect the organisation’s reputation, and they
would protect the organisation’s reputation, possibly even at the expense
of profits.
3. SS3–Act utilitarianism encompasses the idea that in order to create the
greatest overall good it is fundamental to evaluate whether the
consequences of each proposed action will create the greatest benefit for
the greatest number of stakeholders.
4. SS4–Rule utilitarianism expresses the same interest in the greater good,
but, instead of focusing on each separate action, it proposes to establish
and follow those rules which benefit the majority.
5. SS5–Self virtue promotes the idea that good decisions are made by
people who exhibit good individual character virtues.
6. SS6–Others virtue as a particular framework of virtue ethics, concerns
living well with others, promoting social well-being, and would include
what is referred to as care ethics.
7. SS7–Act deontology expresses the notion that the rightness of an act is
not determined by the ruthless application of a moral principle, but by
determining what particular duty is demanded in each particular situation.
Ethical decision making and health care managers | 101
8. SS8–Rule deontology focuses on fulfilling universal duties, such as the
Golden Rule, or acting according to universal principles (e.g. justice, not
harming others, doing good, and respecting autonomy) in all situations.
These subsets of principles are not only widely reflected in the current literature on
ethics (Ferrell et al., 2008), but are also confirmed by the preliminary validation of
the MEP scale (Casali, 2007; 2009).
5.6 Sample characteristics
For this exploratory study, two different target populations have been used. The first
sample (Study 1) comprised academics and nursing students (n=41). In terms of
academic staff, 18 university lecturers from different faculties and universities were
asked to answer the questionnaire. In addition, second year nursing students were
asked to fill in the questionnaire, and 23 out of 60 returned it, providing a 38%
response rate. For the second sample (Study 2) small- and medium-sized-business
managers members of a Business Enterprise Centre were approached. Out of 81
people participating at a business networking breakfast, 41 usable questionnaires
were returned providing a 51% response rate.
5.7 Data analysis
As the objective of this study was to classify respondents based on their real ethical
preferences, rather than pushing them into predetermined boxes, HCA was
performed using the eight ethical sub-scales dimensions of the MEP scale. The
decision to use an HCA method was indicated by the fact that this is an exploratory
study and, as such, there are no predefined clusters to be confirmed and, therefore,
using a non-HCA technique such as K-means would not have been recommended
Ethical decision making and health care managers | 102
(Maenpaa, 2006). HCA can be used to group cases into clusters based on the
assumption that cases that are close to each other in the input feature space are
similar (Everitt, 1993; Gordon, 1999). HCA begins with all cases as separate clusters
and merges the closest clusters until some criterion is satisfied (Everitt, 1993;
Gordon, 1999). The Euclidean distance was used to measure the distance between
cases in the input feature space. The distance between two clusters was calculated as
the average of the pair-wise distances between them (average linkage method)
(Everitt, 1993; Gordon, 1999). The distance between the clusters merged at each step
was used to determine when to stop the clustering. A large distance between merged
clusters indicates that the two clusters may be so dissimilar that it is inadvisable to
merge them.
HCA was performed by using the individual respondents’ computed results for each
of the eight ethical sub-scales from the two cohorts separately (Figure 5.2 and Figure
5.3). The most common visual data representation used with HCA is a dendogram,
which simply reports the degree of similarities between cases by putting the ones that
are most similar closer together and the ones that are dissimilar further apart. By
scrutinising the graphical outcomes of the two HCAs, it is possible to only identify
the cases that are most similar, rather than the ones that are most dissimilar.
However, for the purpose of this study, which is to profile managers based on the
degree of influence that different ethical principles play in their managerial decision-
making process, two questions have to be asked:
1. What are the unique similarities within the clusters?
2. What are the dissimilarities between the clusters?
Ethical decision making and health care managers | 103
In order to answer these questions, it is necessary to further analyse each individual’s
computed score of the eight ethical sub-scales, as the goal of the HCA is to arrive at
clusters of homogeneous people who differ in meaningful ways and display only
small in-cluster variations, but at the same time display a large variation between
different clusters (Hair, Babin, Money, & Samouel, 2003). As previously discussed,
a characteristic for a successful profile instrument is to be able to maximise
differences between clusters, but at the same time to minimise internal differences
(Hair, et al. 2003), thus, two principles have been used to interpret the results of the
HCA. They are:
high internal homogeneity, which generally means that each object included in
a particular cluster has a very strong similarities (for the purpose of this paper
this means that people in a particular cluster has strong similarities in terms of
their ethical preferences).
high external heterogeneity, which means that there are significant differences
between each cluster, and in particular that each cluster represents a unique mix
of preferences about the eight ethical sub-scales (Hair, Black, Babin, Anderson,
& Tatham, 2003; Nunnally & Bernstein, 1994).
Every individual’s computed score from the eight sub-scales was retrieved and
grouped based on the cluster membership from each of the dendograms (Figure 5.2
and Figure 5.3). From the dendogram related to the Study 1 (Figure 5.2), cases were
compared for similarities that would define a cluster. When an anomaly was
discovered, a new cluster was defined and the process of comparison was repeated
until all cases had been allocated to a cluster. For example, the computed results for
case 23 and 32 were put aside, then 39 and 40, then 38, 5 and 8, until an anomaly
was found at case 6, hence creating a new cluster. When all of the respondents and
associated computed scores were sorted into their most relevant cluster by the
Ethical decision making and health care managers | 104
allocated number of data entry on the dendogram, then close clusters such as 23 and
32 and 39 and 40 were examined closely to identify either a reason to join them
together or to keep them separate based on their computed results.
5.8 Results
As a result of a process of mix and match based on the two principles (high internal
homogeneity and high external heterogeneity), a number of strong cohesive clusters
were found, and the overall means for each clusters calculated. Thus, five clusters for
Study 1 (academics and students), and four clusters in Study 2 (small business
managers) were found (see Figure 5.2 and Figure 5.3).
Figure 5.2 Dendogram for HCA on academics and students
Figure 5.3 Dendogram for HCA on small-business managers
Ethical decision making and health care managers | 105
Even though those two studies have resulted in two different totals of clusters (five in
Study 1 and four in Study 2), closer examination of the pattern of responses in each
cluster, based on the average scores of the eight ethical sub-scales, indicates
similarities between the results of the two studies. In fact, four clusters from Study 2
match four of the clusters from Study 1 (See Table 5.1).
Table 5.1 Comparison of HCA results (computed means) from Study 1 and Study 2 in relation to the eight ethical sub-scales
Study 1 Academics and students
SS1 SS2 SS3 SS4 SS5 SS6 SS7 SS8
Economic Egoism
Reputational Egoism
Act Utilitarianism
Rule Utilitarianism
Virtue of Self
Virtue of Others
Act deontology
Rule deontology
Cluster1 1.8 1.5 1.4 1.5 1.3 1.3 1.6 1.2
Cluster2 2.6 2.1 2.3 1.7 1.5 1.8 1.4 1.3
Cluster4 2.2 2 2.4 1.8 2.6 2.4 2.2 2.3
Cluster3 3.5 3 2.2 2 1.7 1.6 1.4 1.8
Cluster5 2.2 1 1.8 1.2 1.8 1.2 1.3 1.2
Study 2 Small-business managers
SS1 SS2 SS3 SS4 SS5 SS6 SS7 SS8
Economic Egoism
Reputational Egoism
Act Utilitarianism
Rule Utilitarianism
Virtue of Self
Virtue of Others
Act deontology
Rule deontology
Cluster1 1.1 1.1 1.1 1 1 1.1 1.2 1.1
Cluster2 2.3 2 1.9 1.6 1 1.2 1.5 1.2
Cluster3 2.1 1.9 2 1.6 2.1 1.8 1.6 1.5
Cluster4 2 2.2 2.6 1.6 2.6 1.9 2.3 2
Table developed for this study
5.9 Discussion
Based on the results from the two studies, four clusters with very similar patterns
were identified in both studies, with one extra cluster found only in Study 1. This
result can be accounted for by the particularity of the second sample (small business
managers). It is important to examine each cluster in detail in order to understand
their differences, particularly in terms of the different degrees of influence that the
eight ethical sub-scales have on decision making. Suitably interpreted, each of the
Ethical decision making and health care managers | 106
five identified clusters can be treated as an MEP, identifying what ethical
frameworks are likely to routinely influence the decision making of the managers
who were surveyed. The results used in the HCA reflected a five-point Likert Scale,
assessing the importance of each item in the respondent’s managerial decision-
making process, where 1 was extremely important and 5 was not important at all.
Therefore, if for a particular ethical sub-scale the mean computed result is 1, or near
to it, that ethical sub-scale is extremely important for that particular MEP. The results
for the five clusters are shown in Table 5.1.
5.10 Developing the Managerial Ethical Profiles
As previously stated, managers use a number of ethical principles in their decision-
making processes. These principles may be from only one ethical framework
(absolutism) or combined from a number of different ethical frameworks (relativism
or pluralism). Where a manager uses principles from different ethical frameworks, a
further differentiation is needed. If a manager switches between ethical frameworks
depending exclusively on the situation, then they would be included in the ethical
approach called ethical relativism. Based on this view of ethics, ethical principles can
be adjusted according to their fit with a particular situation. On the other hand,
ethical pluralists are those managers who draw principles from different ethical
frameworks—they would argue that there are multiple perspectives on an issue, and
each of those views contain part of the truth but none of them, individually, hold the
whole truth. In more operational terms, for the purpose of this paper, managers who
scored all of the ethical principles equally, and who agree that all of those principles
are extremely important, are considered to be ethical pluralists, and those who scored
ethical principles equally but less important are treated as ethical relativists.
Ethical decision making and health care managers | 107
Due to the strong exploratory nature of this study, as the first study using the MEP
scale to profile managerial ethical decision making, the following structure will be
used to interpret the results from the HCA:
Graphically representing each cluster based on their scores on the 8 sub-scales
from the MEP scale (as shown in Table 5.1).
Discussing possible meanings of the results, and how they can be interpreted in
terms of managerial ethical decision making.
Naming the profiles based on their characteristics.
Providing a ‘motto’ to explain each profile in more general terms.
5.10.1 Profile 1: Duty Follower
Figure 5.4 Duty Follower profile according to the eight sub-scales from the MEP scale
Motto: ‘follow duty no matter what the cost.’
This profile is characterised by a very strong preference for non-consequentialist sub-
scales such as deontology and virtue ethics and weak support for economical egoism.
This would suggest that respondents in this cluster see ethics from a particular
perspective and believe that some ethical frameworks are more important than
others. They could, therefore, be also seen as supporting an absolutistic view of
ethics (see Table 5.1). Looking at the items representing the non-consequentialist
ethical sub-scales, it is arguable that the main philosophy behind the ethical decision
making of the managers that belong to this profile is that managers need to possess
Ethical decision making and health care managers | 108
strong character virtues in order to fulfil their duties; in particular, their professional
duties. Managers in this profile are committed to being ethical and applying universal
rules in their decision making, and they are quite strongly opposed to allowing
economic outcomes to override principle. Based on the strong propensity to follow
duties, this cluster has been named the Duty Follower MEP. In this case, decisions
are guided more by rules and duties than by considering the consequences of those
actions. They have a more absolutistic view of morality, and they are very strong
advocates for particular universal duties such as do not lie or do not kill. Managers
with this profile are very faithful to rule and duty, but the related risk is that this can
be achieved at the expense of flexibility. For instance, if an organisational rule is to
‘not accept any gifts from clients or suppliers’, then a Duty Follower would not
accept a gift under any circumstances. Therefore, a Duty Follower manager visiting a
Chinese client during the Chinese New Year would turn down a small golden gift—
given as a wish for a prosperous year, as per tradition—despite the likelihood of
offence to the client and their culture. The Duty Follower’s major concern is with the
moral standing of themselves, rather than the consequences for the reputation of the
organisation.
5.10.2 Profile 2: The Chameleon
Figure 5.5 Chameleon profile according to the eight sub-scales of the MEP scale
Motto: ‘when in Rome, do as the Romans do’
Ethical decision making and health care managers | 109
This profile is very different from the previous one, due to equal importance being
given to each of the eight ethical sub-scales, rather than a strong preference for a
particular one. However, the responses related to this cluster are not very strong (see
Table 5.1), suggesting that people in this cluster might use different ethical
frameworks, not at the same time, but more instrumentally to a particular situation.
The ethical philosophy behind this profile is that the manager is aware of the
different ethical positions, and will decide which best suits a particular situation.
Managers in this group are not strongly committed to one type of ethical theory;
therefore, they might use particular ethical principles in order to protect the
organisation’s reputation by following those rules that either promote the greatest
good or uphold human principles. This profile has been named the Chameleon. Just
as the reptile of the same name changes its skin colour to fit in with its surrounds,
these managers assess the different ethical viewpoints and decide which is the most
appropriate for a particular situation. Arguably, the Chameleons have a more
practical view of morality, as they do not rigidly hold a particular position but they
assess the context first and then apply the ethical framework that is most appropriate
to that particular situation. However, while this profile is more flexible than the Duty
Follower, there is also a risk that all of this flexibility could simply encourage
decision makers to blend in with the prevailing culture—when in Rome, do as the
Romans do—rather than engaging with it proactively. Relatively speaking,
Chameleons, compared to others profiles, have less independence in their ethical
decision-making capacity because they are strongly affected by others of significance
(experts or superiors) and the organisational culture. Using a business example, a
Chameleon would be more likely to accept an expensive gift with no reservation, and
Ethical decision making and health care managers | 110
most likely keep it as well, if that is a common practice in that country. Too many
Chameleons in an organisation may be a barrier to effectively challenging and
changing unhealthy organisational cultures.
5.10.3 Profile 3: Guardian Angel
Figure 5.6 Guardian Angel profile according to the eight sub-scales from the MEP scale
Motto: ‘follow those duties that promote the greatest good’
In this profile, like the Duty Follower, all of the non-consequentialist ethical sub-
scales, plus rule utilitarian, are the most important—a combination that can be
summarised as managers who not only make sure that they conform to rules and that
the dignity of others is maintained, but also keep an eye on the overall outcomes (the
greatest good for the greatest number). They are strongly committed to fulfilling the
obligations that go with a public or professional role and, therefore, they feel a duty
to consider the consequences of their decisions and to treat others fairly. Due to very
nature of this profile, which is to protect and to guide, it has been named the
Guardian Angel. Like the Duty Followers, managers in this group tend towards an
absolutistic view of ethics, but are not as narrow. They obey rules but, at the same
time, they use their wisdom to consider the impact on others of so doing. Thus, if
offered a gift by a client they would not turn it down simply because the
Ethical decision making and health care managers | 111
organisation’s code of conduct strictly prohibits accepting gifts; they would weigh up
honouring the duty of ‘not accepting a gift’ against the duty to protect organisational
reputation and respect for other cultural traditions. They would accept the golden gift
at Chinese New Year. A risk with this profile is that the potential conflict between
duties may lead to inconsistent responses.
5.10.4 Profile 4: The Defender
Figure 5.7 Defender profile according to the eight sub-scales from the MEP scale
Motto: ‘the defender of the faith’
The results for this cluster are not only strong on the non-consequentialist ethical
sub-scales (SS8, SS7, SS6, and SS4) but also equally strong, if not stronger, on SS1–
Reputational Egoism. Managers in this group are very loyal to the organisation, and
they would make decisions to protect the reputation of the organisation. Good public
opinion about oneself and one’s organisation are more important than the bottom
line. People in this profile would spend more time weighing up what is good versus
what is good for the organisation. The virtues of the people in this cluster are
directed strongly towards the well-being of their organisation. Those people are
Ethical decision making and health care managers | 112
extremely important for the company because they are the most loyal to the
company, and are less likely to undermine its goals by pursuing their own individual
self-interest (Casali, 2008a). However, the excessive loyalty of the Defender is not
always helpful. Due to the fact that Defenders have scored low on the sub-scale of
self virtue, it may indicate a lack of focus on internal morals. This situation could
increase the chances of engaging in illegal or unethical actions in order to protect the
organisation’s reputation. Like an avid Defender in a soccer team, they would accept
the risk of a penalty or being sent off the field—by taking down an opponent in front
of goal—for the good of the team. Another example would be the behaviour of some
employees of the Australian Wheat Board (AWB). Its former chairman, when
accused of bribe and breaching a number of United Nations oil-for-food sanctions,
said in a statement issued by his lawyers: ‘I emphatically deny that I acted in any
manner other than in the best interest of AWB and its shareholders’ (McMahon,
2007). Going back to the example of the Chinese gift, managers in this profile would
accept the gift only if that action would benefit the organisation.
5.10.5 Profile 5: The Knight
Figure 5.8 Knight profile according to the eight sub-scales from the MEP scale
Motto: ‘Being the best I can be, doing the best for everyone, and doing the right
thing in all situations’
Ethical decision making and health care managers | 113
The final profile identified in this study represents the viewpoint of ethical pluralism.
The average results on all of the eight ethical sub-scales are between 1 (extremely
important) and 2 (very important). This MEP has been named the Knight. These
managers are strongly influenced by a large number of factors, a fact that suggests
that they are constantly searching for the best balance between their own values and
the organisation’s values, and also keeping an eye on both economic factors and the
impact of decisions on all stakeholders. They try to maximise the good in both
themselves and the world around them. Their desire is to pursue happiness and
excellence, be a good person, work for a good organisation, and build a better world
(Morse, 1998). Managers who are part of this profile are ethical pluralists, but in a
much stronger sense than the Chameleons. They will take into consideration all of
the individual moral principles and put them into a more universal than local context.
A possible downside of being the only profile representing ethical pluralism is that
the knight might have too high an expectation about their leaders’ and their
organisation’s espoused values and therefore can be easily disappointed (Minkes,
Small, & Chatterjee, 1999).
As previously suggested, the five MEPs represent a mix of ethical principles that
managers are influenced by in their managerial ethical decision-making processes.
For example, the Duty Follower is a profile that characterises managers as strongly
devoted to following duties and, in the event of competing duties, would prioritise
them not based on expected economic outcomes, but on fulfilling universal duties or
protecting rights. The Guardian Angel is similar to the Duty Follower; however, the
main difference between the two is grounded in the idea that Guardian Angels would
Ethical decision making and health care managers | 114
follow duties that not only create the greatest good for the greatest number of people
but also maintain respect for the individual. On the other hand, the Defender profile
suggests that managers would prioritise choices based on the degree of impact that
those possible options would have on the organisation’s reputation even at the
expense of profit or fulfilling universal duties. The Chameleon is the most relativist
profile of all, suggesting that managers in this profile are strongly influenced by
other colleagues of significance or by the organisational culture, or both, as they are
aware of the different conflicting ethical principles, but have not developed a
framework for prioritising them in the event of conflicting principles. Last, but not
least, is the Knight. In contrast to the Chameleon, managers in this profile have
developed that framework to assess conflicting principles, and underpinned it with
their personal and professional experience and wisdom. A Knight profile suggests
that managers would strongly rely on their own skill and knowledge and be less
influenced by significant others or the organisation.
5.11 Conclusion
A problem of many current ethical decision-making profiling techniques is that they
use a priori clusters based on pre-existing schools of moral philosophy, which
reduces the capacity to adequately capture the reality of decision making. This paper
has established that allowing respondents to create their own clusters, rather than
being simply allocated into one of the schools of moral philosophy, can significantly
advance current understandings about managerial ethical decision making in
practice. Giving respondents the opportunity to pick and choose particular
dimensions reflecting different ethical frameworks has led to the development of a
number of a posteriori clusters. As a result of this study, five clusters have been
Ethical decision making and health care managers | 115
identified in the first study and only four have been found in the second study, which
can be explained by the nature of the second cohort. The missing profile from the
second study is the Duty Follower, a profile characterised by a strong devotion to
universal principles and organisational duties but a strong disregard for economical
factors (see Table 5.1). While people working in large organisations may have the
luxury of letting someone else look after the bottom line, it is arguable that small-
business managers, by their very nature, cannot disregard the bottom line; otherwise,
they would be out of the business immediately. It is important to emphasise that
although all five profiles are ethical, they would look at the same problem and assess
it based on different criteria. For example, a Duty Follower would make sure that
universal rights and duties have been fulfilled, even at a great cost in terms of money,
efficiency, or effectiveness; whereas a Chameleon would mostly ask an expert
opinion and follow that advice. A Knight would look at a problem from all points of
view and then try to find a solution that would maximise the benefit to all. The
Defender would make any decision that would improve an organisation’s reputation
or at least protect it at all costs. Last, the Guardian Angel would seek to satisfy
universal duties, but also take economic factors into account, thereby seeking the
greatest good for the greatest number of people but not at the expense of the
business.
5.12 Possible practical application for the MEP scale
Despite the fact that this is exploratory research, some possible practical use for the
MEP scale can be suggested. The MEP scale could be used in assessing possible
board members: having each of the five profiles represented could increase a board’s
effectiveness and efficiency and reduce the risk of groupthink. At the individual
Ethical decision making and health care managers | 116
manager level, the MEP scale can be used as a means of self education, informing
individuals about their ethical strengths and weaknesses (based on their profile). The
MEP scale could also be used by a multinational organisation to map their
subsidiaries around the globe based on the concentration of the different MEPs. They
would be able to better assess the risks associated with giving a high degree of
decision-making autonomy to a subsidiary with a strong concentration of Duty
Followers looking for some rules to follow. Knowing that the managers in an
organisation have differing ethical decision-making profiles would also assist in
tailoring ethics training, and internal communication on ethical issues, to the
workforce, with trainers and senior management knowingly adopting a variety of
strategies to more successfully communicate and implement ethical regimes.
5.13 Future research and limitations
The purpose of this study is to use statistical techniques (HCA) to identify clusters
based on responses to the MEP questionnaire. Further research in this area is needed
to address a number of questions and to advance understanding about the MEPs
themselves. Questions that should be further investigated include:
Are the MEPs stable across different countries, sectors, and cultures?
Are there any particular individual traits that belong to a particular profile?
Does organisational size affect MEPs?
The results of this study indicate that the MEP scale will be a useful instrument for
further inquiry into managerial ethical decision making. As this is only an
exploratory study based on the preliminary results of two rather small samples (41
respondents), the findings should be viewed with some degree of caution in terms of
their generalisability. Nevertheless, each of the two samples were analysed using a
Ethical decision making and health care managers | 117
statistical tool that performs best with small sample data and performs in a reliable
and valid way—this paper reproduced four of the five overall ethical profiles across
the two studies.
5.14 Footnote
The five profiles discovered in Study 1 were also found in a larger study based on
441 health care managers in Australia. A paper reporting the findings of this more
confirmatory research has been presented and published in the peer review section of
the ANZAM (Australian and New Zealand Academy of Management) 2008
conference proceedings.
Ethical decision making and health care managers | 118
PART 3:
The main study results and conclusion
Part 3 begins with a chapter on the MEP scale development (Chapter 6) based on the
results from the survey of 441 health care managers in Australia. This is followed by
a chapter that validates the five profiles that were found as part of the pilot study
section of the thesis (Part 2), based on a large sample (n=441).
The purpose of Chapter 6 is to develop a scale to test the multidimensional model
developed in Chapter 3. It reports the further development of the MEP scale, which
is capable of measuring the degree of influence that ethical factors have on
managerial decision making.
Chapter 7 fully implements the horizontal approach to ethical decision making
described in paper 2 (Chapter 3) by analysing more than 40 factors influencing health
care managers in Australia. A range of individual, external, and organisational
factors are measured and analysed with reference to the ethical profiles.
Chapter 8 concludes the thesis by restating the research question, summarising the
results, reviewing the limitations of the research, and offering suggestions for further
research.
Ethical decision making and health care managers | 119
Chapter 6
Developing a multidimensional scale for
ethical decision making
6.1 Abstract
This chapter reports on the development of the Managerial Ethical Profile (MEP)
scale. The MEP scale is a multilevel, self-reporting scale measuring the perceived
influence that different dimensions of common ethical frameworks have on
managerial decision making. It is designed to be particularly but not exclusively
applicable in the context of health care management. The MEP scale measures on
eight sub-scales: economic egoism, reputational egoism, act utilitarianism, rule
utilitarianism, self virtue of self, virtue of others, act deontology, and rule
deontology. Confirmatory Factor Analysis (CFA) was used to provide evidence of
scale validity. Future research needs, and the value of this measure for business
ethics, are discussed.
6.2 Introduction
Increasingly, in order to reduce the likelihood of unethical business practice,
organisations, governments, and managers are seeking new ways to better understand
what guides managerial ethical decision making. Recently, there have been high-
profile examples of the catastrophic impact that unethical decisions taken by
executives have had on stakeholders. The energy company, Enron Corp., and the
telecommunication company, WorldCom, are two prominent examples of how the
Ethical decision making and health care managers | 120
wrongdoings of executives can not only end in bankruptcy for the company
concerned, but can also, through a snowball effect, financially and emotionally
devastate employees, investors, suppliers, customers, partners, and governments.
It has been both theoretically argued and empirically tested that an individual's
ethical beliefs or ideology influence their approach to ethical judgments and decision
making (Barnett, Bass, & Brown, 1996; Barnett, Bass, Brown & Hebert, 1998;
Davis, Johnson, & Ohmer, 1998; Forsyth, 1980, 1981; Whitcomb, Erdener, & Li,
1998). Arguably, knowing what influences managers in their decision-making
process, and, more specifically, what ethical principles they attempt to satisfy when
making business decisions, could help to diminish the likelihood of further corporate
scandals. One possible positive contribution towards increasing ethical practice in
organisations, then, would be a capacity to accurately assess these ethical factors that
influence the ethical decision-making capabilities of individual managers and to
tailor educational and administrative needs accordingly.
Measuring ethical decision making is not a new topic, and there are number of scales
that have been used over the years to offer insights on this matter. For example, the
Defining Issues Test (DIT) by Rest (1979) has been used in many studies to measure
stages of moral development (Shawver & Sennetti, 2009; Woodward, Dais, & Hodis,
2007; Rogers & Smith, 2001; Paradice & Dejoie, 1991), while the Ethics Position
Questionnaire (EPQ) by Forsyth (1980, 1981, 1985, and 1992) has also been used to
ascertain ethical ideology (Davis, Andersen & Curtis, 2001; Etter, Cramer, & Finn,
2007). Similarly, the Managerial Judgment Test (MJT) by Lind (1978), which has
been administered to about 15,000 participants (Gross, 1997), measures moral
Ethical decision making and health care managers | 121
judgment (Moutatidou, Goutza & Chatzopoulos, 2007; Comunian & Gielen, 2006),
and the Managerial Values Profile (MVP) by Sashkin et al. (1997) focuses on
measuring individual ethical preferences (French & Casali, 2008; Zgheib, 2005).
Finally, the Multidimensional Ethics Scale (MES) by (Reidenbach & Robin, 1988;
1990) is used also to measure individual ethical preferences (Gupta, 2010; Jung,
2009; Cohen, Pant & Sharp, 2005). All of these tools have areas of strength and they
all have enhanced understanding of ethical decision making, but they also have a
number of flaws. If these were eliminated, it could greatly contribute to our current
knowledge of ethical decision making.
The aim of this paper is to develop and validate the MEP scale, a new scale
purposely developed to overcome some of the flaws that limit the current tools for
ethical decision making.
6.3 Literature review of tools for measuring ethical decision making
A number of instruments or scales (see Table 6.1) that measure ethical decision
making have been identified in the literature by reviewing articles that have
empirically tested this matter in order to profile ethical decision makers. All of the
scales identified from the current literature (see Table 6.1) investigate ethical
decision making by using one or more of the following three approaches:
1. Testing levels of moral development based on Kohlberg’s stages of moral
development (Rest 1979; Lind 1978, 1995).
2. Testing individual preferences with respect to relativism and idealism
(Forsyth 1980, 1981, 1985, 1992).
Ethical decision making and health care managers | 122
3. Testing individuals by categorising them according to ethical principles:
egoism, utilitarianism, social justice, and individual rights perspectives
(deontology) (Sashkin et al., 1997; Reidenbach & Robin, 1988; 1990).
The first two scales, the Defining Issue Test (DIT) by Rest (1979) and the
Managerial Judgment Test (MJT) by Lind (1978; 1995), have been extensively used
to investigate ethical decision making (Vitell & Ho, 1997). Both have been designed
around Kohlberg’s (1969) theory of cognitive moral development; what
differentiates them, however, is their approach to measuring cognitive moral
development. The DIT focuses on measuring the extent to which an individual uses
principled considerations in making moral decisions (stages 5 and 6 in cognitive
moral development according to Kohlberg), or what is also known as stage
preference. The MJT on the other hand determines how consistently an individual
follows a particular principle, or what is known as stage consistency (Ishida, 2006).
Both tests use responses to ethical dilemmas to determine the respondent’s stage of
moral development (Ishida, 2006). They exhibit two major weaknesses when applied
to business decision making. Firstly, respondents are asked to imagine themselves in
fictitious scenarios that were developed with the precise intent of stimulating a moral
reaction. While offering some valuable insights, this might not fully represent what
the respondent would normally do in a similar real-life situation (Krebs & Denton,
2005). Secondly, both tests are designed so that respondents must fit into either one
stage of moral development or another; the possibility that they might sit between
these stages is excluded.
Ethical decision making and health care managers | 123
Table 6.1 Summary of five tools for measuring ethical decision making
Tool Scenario-based
Forced
choice
Mutually
exclusive
categories
Non-value-neutr
al
Moral theories
Multi dimension
al categories
Defining Issue Test (DIT) by Rest
(1979) Yes No Yes Yes No No
Managerial Judgment Test (MJT) by Lind
(1978)
Yes No Yes Yes No No
Ethics Position Questionnaire (EPQ)
by Forsyth (1980,1981,1985,19
92)
No No Yes No No No
Managerial Value Profile (MVP) by
Sashkin et al. (1997) No Yes Yes No Yes No
Multidimensional Ethics Scale (MES) by Reidenback &
Robin (1988, 1990)
Yes No No No Yes No
Another three scales that have been used to measure ethical decision making are the
Ethics Position Questionnaire (EPQ) by Forsyth (1980, 1981, 1985, 1992), the
Managerial Value Profile (MVP) by Sashkin et al. (1997), and the Multidimensional
Ethics Scale (MES) by Reidenbach and Robin (1988, 1990). Forsyth (1980)
developed the EPQ to assess personal moral philosophy. It asks individuals to
indicate their acceptance of items that vary in terms of relativism and idealism. The
relativism scale, for example, includes such items as: ‘different types of moralities
cannot be compared as to “rightness”’ and ‘what is ethical varies from one situation
to another’. The idealism scale, on the other hand, measures one’s perspective on
positive and negative consequences, with such items as: ‘a person should make
Ethical decision making and health care managers | 124
certain that their actions never intentionally harm another even to a small degree’ and
‘if an action could harm an innocent other then it should not be done’ (Forsyth,
1980). Overall, high scorers on the idealism sub-scale of the EPQ more strongly
endorse items that reflect a fundamental concern for the welfare of others, whereas
those who receive high scores on the relativism sub-scale of the EPQ tend to espouse
a personal moral philosophy based on the rejection of moral universals (Forsyth,
Nye, & Kelley, 1988).
The MVP (Sashkin et al., 1997) uses 12 forced-choice items to ascertain the values
that guide an individual’s decision making. The scale comprises 24 items, eight for
each of three ethical frameworks used as guiding values in decision making:
utilitarianism, individual rights (deontology), and social justice (Zgheib, 2005). The
expected result for the MVP is a score varying from 0 to 8 for each of the three
ethical frameworks tested. The respondent’s ‘profile’ is designated as the ideology
with the highest score. The last instrument for measuring ethical decision making is
the MES, developed by Reidenbach & Robin (1988, 1990). This scale summarises
five ethical philosophies: justice, relativism, egoism, utilitarianism, and deontology.
The MES is a multi-item scale that asks respondents to indicate the extent to which
they believe a given scenario is ethical, based on the different ethical criteria
(Reidenbach & Robin, 1988; 1990).
By looking at Table 6.1, it is possible to see that the most common profiling
instruments for ethical decision making have a number of flaws, some which belong
to all instruments and some specific to few of them. Most of the instruments tend to
concentrate on psychological aspects rather than moral theories. Both the DIT and
Ethical decision making and health care managers | 125
the MJT are based on the theory of moral cognitive development by the psychologist
Lawrence Kohlberg (1979), and the EPQ focuses on the dichotomy between
relativism and idealism (two views of ethical principles). Only two out of five
instruments reviewed in this paper account for the possible influence of moral
theories themselves rather than moral cognitive development: the MVP assesses
utilitarianism, individual rights (deontology), and social justice; the MES measures
justice, egoism, utilitarianism, and deontology. However, none of the instruments
take into account virtue ethics—an important moral theory that has been found
capable to influence ethical decision making.
Of those studies that do take into account moral theories, none use a
multidimensional approach to ethical frameworks; they all tend to treat ethical
frameworks such as egoism, utilitarianism, and deontology as unidimensional. The
vast majority of instruments (except the MES) use mutually exclusive categories, a
feature that limits the capacity to capture possible crossovers between the different
categories. As people do not necessarily fit into only one category, or draw upon
only one framework to make ethical decisions in all situations, this limitation could
reduce the importance of the findings and the ability to use them to profile managers
based on their actual ethical preferences.
Reviewing the specific flaws for each of the instruments, the DIT, MJT, and MES
use scenarios purposely developed to provoke an ethical response. The MVP uses 12
forced-choice items—respondents have to choose one statement over the other—and
it assumes that people will clearly belong to one of the three specified value systems
(Sashkin et al., 1997). There is, therefore, a lack of precision. By forcing respondents
Ethical decision making and health care managers | 126
to choose between two competing items, their answers might not be realistic. They
may have wanted to pick one of the other items also. Furthermore, the instrument
does not measure the intensity of ethical preference—there is no way to know how
strong or weak their choices were. In other words, this instrument does not measure
the degree of importance that each respondent attaches to each of the 24 items. The
MES is the only instrument that measures the degree of influence of different ethical
frameworks and that at the same time allows respondents to score across the different
factors. However, even this tool does not address virtue ethics as a category in ethical
decision making, and also does not consider that moral theories are themselves
multidimensional. It is clear, therefore, that the current tools available to measure
ethical decision making are less than optimal for profiling managerial ethical
decision making and a more complex, but at the same time holistic, approach to
managerial ethical decision making is overdue.
The shortcomings identified in the current ethical decision-making profiling tools
provide a clue to possible improvements to profiling ethical decision making,
particularly by improving the multidimensionality of the ethical frameworks
influencing ethical decision making. Many of the current generation of managers
have been introduced to these various major forms of moral theory—albeit not to the
depth that would satisfy a dedicated philosopher—in their business ethics training.
Even where this is not so, it is arguable that the various major ethical theories, such
as egoism, utilitarianism, virtue ethics, and deontology, reflect high-level
systemisation of approaches already intuitively taken in everyday decision making
(Jamieson, 1991, p. 479). Given that moral theories will, to some degree, influence
decision making in the workplace, then, the MEP scale attempts to measure the
Ethical decision making and health care managers | 127
degree of that influence in a way that overcomes the shortcomings of previous
studies, which have given little attention to the multidimensionality of these ethical
frameworks.
Specifically, the present study has developed a self-reporting instrument
(questionnaire) that can, by measuring the degree of influence of different ethical
principles, generate a profile of each manager’s ethical decision-making style. Such
an instrument can form the basis of self-assessment or be used to identify strengths
and weaknesses in the decision-making capabilities of management teams in both
small and large organisations.
6.4 Theoretical assumptions for the MEP scale
The first task in developing this new scale is to identify a number of theoretical
assumptions that can be used as pillars of the MEP questionnaire.
Assumption 1: Managerial ethical decision making incorporates a number of
ethical criteria, articulated in day-to-day business practice terms, that reflect
the various major schools of moral philosophy.
The initial development stage of the MEP scale converted the different norms,
values, and definitions of the four major schools of moral philosophy into items to be
included in the new scale as a practical list of multiple criteria for managerial
decision making.
Ethical decision making and health care managers | 128
Assumption 2: Each ethical criterion of the MEP scale will hold the same
value, and the different profiles that arise from the analysis of the data will not
be viewed as more or less ethical than each other.
In philosophical circles, the relative merits of the various moral theories, including
the four major schools of moral philosophy (ethical egoism, utilitarianism,
deontology, and virtue ethics) are vigorously contested, with various authors arguing
that one system or another is more rationally grounded than the others. A number of
scholars have argued for a pluralist approach—each respective theory is suited to
solving different moral dilemmas in differing situations and therefore each school of
moral philosophy is morally acceptable (Hinman, 2003). Postov (2006) also views
ethical pluralism as a meta-ethical stance that recognises competing moral views or
schools of moral philosophy as morally valid. At the outset, a difficulty confronting
the development the MEP scale was how to construct a questionnaire that did not
embed the kind of hierarchical assumptions about these various systems that have,
for example, dogged the Kohlbergian approach. Kohlberg’s (1969) theory, for
example, established a hierarchy from egoism at the lowest level to deontology at the
highest, with context-based decision making seen as less ethical than that done from
a more universal viewpoint. The present study seeks to avoid these hierarchical
assumptions. Because the MEP scale is profiling decisions made in organisations,
and an organisation principally exists to fulfil its organisational mission, the
teleological approach, of which ethical egoism is one expression, for example, will
naturally tend to be more deeply embedded in managerial decision making. Also, as
it is the task of the MEP scale to measure the relative influence of the various moral
frameworks on an individual manager’s decision making, it would be detrimental to
make a priori assumptions about the relative worth of these differing ethical styles.
Ethical decision making and health care managers | 129
As the purpose of the study is to measure the actual differences in these factors, the
various schools of moral philosophy and the criteria have been equally weighted in
the test instrument.
Assumption 3: Each school of moral philosophy is multidimensional.
A school of moral philosophy is not conceptually unified; each school has different
dimensions, and, therefore, managers could be influenced by one particular
dimension of a given school but not by others. For the purpose of this study, two
dimensions for each school of moral philosophy have been chosen.
Ethical egoism is the school of moral philosophy or ethical framework that judges
the ethicality of an action based on outcomes that maximise the interests of an
individual. It is ethical egoism, rather than psychological egoism, because the ethical
egoist argues that everyone, not just oneself, should act out of self-interest. In the
business context, this ethical egoism may be expressed in two ways: by maximising
economic outcomes or by maximising reputational outcomes. One dimension would
promote the best outcomes for the individual agent (me or, by extension, my
organisation) in terms of economic interests—fulfilling economic criteria such as
profit and reduced costs—while the other dimension would be focused on
reputational interests—protecting and enhancing the status or reputation of one’s
organisation. For example, Schnietz and Epstein (2005) found that “a reputation for
social responsibility protected firms from stock declines associated with crisis, even
when controlling for possible trade and industry effects” (p. 327). If this is the case,
then ethical egoism would not necessarily preclude corporate social responsibility.
For managers, ego focus can be individual or organisational because,
Ethical decision making and health care managers | 130
psychologically, individuals can identify their organisation as an extension of
themselves. They can identify with the organisation so strongly that they would act
in a way to protect its reputation, in their own interest, perhaps even at the expense of
potential profit.
The ethical framework of utilitarianism is also consequentialist but focuses on
creating the greatest overall good for the greatest number of people when considering
the consequences of any actions. Within this school, there are two main
dimensions—act utilitarianism and rule utilitarianism (Frankena, 1973; Rallapalli,
Vitell, & Barnes, 1998; Veatch, 1998; Hinman, 2003; Casali, 2007). Act
utilitarianism encompasses the idea that in order to create the greatest overall good it
is fundamental to evaluate each proposed action as to whether it will create the
greatest benefit for the greatest number of people (stakeholders). Rule utilitarianism,
on the other hand, does not focus on discrete actions but proposes that one ought to
follow those rules that would benefit the majority.
While utilitarian frameworks assess the external effects of actions, the virtue ethics
framework is focused internally on the individual, either on individual character
traits (self virtue) that promote personal well-being, or living well with others and
caring for others (other virtues). This latter dimension within the school of virtue
ethics would include a contextual morality, which many feminists defend (Gilligan,
1977), including an ethics of care or responsibility.
Deontological ethics focus not so much on either actions or character traits but prima
facie rights and duties (Frankena, 1973; Rallapalli, Vitell, & Barnes, 1998; Veatch,
Ethical decision making and health care managers | 131
1998; Hinman, 2003; Casali, 2007). Rule deontology, the main form of deontological
ethics, focuses on fulfilling universal duties, such as the golden rule, or acting
according to universal principles (for example, justice, not harming others, doing
good, and respecting autonomy) that would apply to all agents in all situations
(Frankena, 1973; Casali, 2007). According to act deontology, however, the rightness
of an act is not determined by the ruthless application of a moral principle, but by
determining more intuitively what universal duties are demanded in the particular
situations (Frankena, 1973; Casali, 2007).
6.5 Method
The items for the MEP questionnaire were developed using a two-step process
(DeVellis, 2003). The first step involved reviewing the current literature on business
ethics, ethics, philosophy, and religion as an initial source of information for the
development of the items. The second step was to identify and consult with experts
in the above fields for validation of items and possible adjustments. A total of 34
statements were developed and then refined to 28 statements through comparison
with the literature. A content validity test of these 28 items was performed by
interviewing 14 experts in the area of moral philosophy, business ethics, and religion.
The experts were asked to check the appropriateness of assigning these 28 items to
the eight dimensions of the major ethical theories. Four items were found
inappropriate for inclusion in any of the dimensions by the majority of the experts
and were therefore eliminated from the scale, leaving 24 items in the final survey
(see Appendix 1). The scale items were measured on a five-point scale ranging from
‘extremely important’ (=1) to ‘not important at all’ (=5). There were no reverse-
coded statements in the scale. The questionnaire was distributed by e-mail to 2,473
Ethical decision making and health care managers | 132
managers from the health care industry in Australia. The collected responses (n=441)
were analysed for their scale properties using a CFA using the Amos™ 7.0 structural
equation modelling software. CFA seeks to determine if the number of factors and
the loadings of measured variables (indicators) conform to what is expected on the
basis of a priori theory. Indicator variables are also selected on the basis of a priori
theory, and factor analysis is used to see if they load as predicted on the expected
number of factors. The researcher’s a priori expectation is that each factor (the
number and labels of which may be specified a priori) is associated with a specific
subset of indicator variables. A minimum requirement of CFA is that the number of
factors in the model be hypothesised beforehand, but also which variables will load
on which factors will also be posited. For the purpose of this study, eight factors are
considered: economic egoism, reputational egoism, rule utilitarianism, act
utilitarianism, virtue of self, virtue of others, act deontology, and rule deontology. In
developing the MEP scale, this study has used CFA as the main strategy to assess the
psychometric properties of the scale. CFA is used to test theory, and this study has
created the eight ethical sub-scales construct to be tested.
Ethical decision making and health care managers | 133
Table 6.2 MEP scale item loadings: Model A (eight-factor model)
Factors/Items Loading AVE CR
Economic Egoism 1. providing the highest economic return (profit)
for the organisation .57
2. minimising costs for the organisation .80 .55 .72 3. optimising resources of the
district/hospital/unit/dept .67
Reputational Egoism 1. protecting the reputation of the organisation .74 .69 .65 2. being in line with the organisational mission .65
Rule Utilitarianism 1. not harming the clients/patients .41 2. respecting organisational rules and regulations
that have been created for the greatest benefit for all stakeholders
.61 .51 .41
Act Utilitarianism 1. creating the greatest overall benefit for the local
community .92 .85 .84
2. creating the greatest overall benefit for the wider community
.79
Virtue of Self 1. being most in line with your core personal values .83 .87 .86 2. being most in line with the person you want to
be .91
Virtue of Others 1. respecting dignity of those affected by the
decision .78
2. being able to empathise with clients .75 3. acting openly when making decision .66 .69 .86 4. making ‘care for the sick’ paramount in
determining decision alternatives .58
Act Deontology 1. giving the opportunity to all affected parties or
their representatives to have input into the decision making process
.63 .81
2. treating others as you want others to treat you .76 .68 .88 3. treat people as ends not as means .66
Rule Deontology 1. ensuring that confidentiality is maintained at all
times .73
2. maintaining a fair process at all times .84 .78 3. ensuring that the organisation “duty of care” is
maintained at all times .76
Ethical decision making and health care managers | 134
6.6 Research sample
The MEP scale was finalised and converted into an online instrument linked to an e-
mail message sent to the members of a professional association of health care
managers in Australia with 2,473 members. As a result of this study, 441 usable
questionnaires were returned, which is equal to a response rate of (18%). Of the
sample, 244 (55.3%) were female and 197 (44.7%) were male. The mean age was 44
(SD=.921). Almost half of the people in the sample were middle managers (43.8%),
16.1% were senior managers, 15% corporate governance, 13.2% supervisors, and
12% consultants. 79.4% had undertaken postgraduate studies of some kind, and
20.6% had an undergraduate degree. The majority of respondents in the sample
(62.1%) worked for the government, 28.3% for the private sector, and 9.5% for
religious organisations. In terms of work experience, 30.8% of the sample had three
years or less of experience, 49% had more than three but no more than 10 years of
experience, and 20% had more than 11 years experience. The largest group of
respondents were administrative staff, 268 (60.8%), 118 (26.8%) were medical
(doctors and nurses), and 55 (12.4%) were allied health staff.
6.7 Results
Construct validity was assessed by identifying the concepts underlying respondents’
scores on this scale. To determine if the scale had a meaningful component structure,
it was factor analysed. Using the data collected from the sample (n=441), six models
(see Table 6.3) were tested using AMOS™ 7.0 SEM software. The item loading (see
Table 6.2) varied between 0.4 and 0.9, which is an acceptable result (McDonald,
1999).
Ethical decision making and health care managers | 135
The fit of the model was assessed using indices such as: chi square, Relative Fit
Analysis, Root Mean Square Error of Approximation (RMSEA), Confirmatory Fit
Index (CFI), Adjusted Goodness of Fit (AGFI). The chi square (χ2) statistic assesses
absolute fit of the model to the data, and a non-significant χ2 supports the perfect fit
of the model. Two recognised limitations of the χ2 statistic are its sensitivity to
sample size and its assumption of the correct model. Therefore, no restrictive model
with positive degrees of freedom is able to fit real data, and such models will often
be rejected by a formal significance test with a sufficiently large sample. The relative
fit of a proposed model can be assessed by using different goodness of fit indices.
For example, as the ratio of chi square to degrees of freedom (χ²/df) (Hoelter, 1983)
decreases and approaches zero, the fit of the model improves. In particular, the
values of 3.00 or less indicate an adequate fit (Byrne, 1989). Accordingly, other fit
indices must be used for judging model fit. The RMSEA represents closeness of fit,
and values approximating 0.06 and 0 demonstrate a close or exact fit of the model
(Kline, 2005). In addition, a CFI greater than or equal to .9 suggests an acceptable fit
and greater than .95 a good fit (Kline, 2005).
Table 6.3 Results of Confirmatory Factor Analysis
Model CFI SRMR RMSEA χ² df χ²/df Λ χ² Λdf P-value
Model A (a priori 8-factor structure)
.933 .0467 .057 393.75 161 2.44
Model B: baseline (1-factor structure)
.919 .0601 .060 459.59 178 2.58 65.84 17 0
Model C (4-factor structure)
.924 .0557 .059 441.03 176 2.50 47.28 15 0
Ethical decision making and health care managers | 136
Notes. Deontology =act deontology and rule deontology; Virtue Ethics= virtue of others and virtue of self; CFI = comparative fit index; RMSEA = root mean square error of approximation; SRMR=standardised root-mean-square residual. The CFI range from 0 (poor fit) to 1 (perfect fit); values of .95 or higher are indicative of a good model fit. RMSEA values lower than .08 are considered to reflect adequate fit, values less than .05 to .06 indicate good fit. SRMR value less than .08
As suggested by Kline (2005, p. 180), a first step in testing for discriminant validity
of a model structure with multiple latent factors is to reject the possibility that a
single factor structure (baseline model) fit the data well. The baseline model in this
paper (Table 6.3, Model B) demonstrated a poor fit of the data: χ² (178) = 459.59,
p<.001; CFI = .919, RMSEA = .060, SRMR = .0601. The second step towards
validating the fact that the eight-factor structure fits the data better is to reject the
model that supports the thesis that the schools of moral philosophy are
unidimensional and, therefore, a four-factor structure (Table 6.3, Model C)
demonstrates only a marginal adequate fit of the data (χ² (176) = 441.03, p<.001; CFI
= .924, RMSEA = .059, SRMR = .0557). Also, seven latent factors have been tested
against the eight-factor model structure (the model supported by this paper) by
combining highly correlated sub-scales, but they all resulted in a poor fit (see Table
6.3). However, the eight-factor structure (Table 6.3, Model A), supported in this
Model D1 (7-factor structure (deontology combined)
.921 .0491 .061 444.01 168 2.64 50.26 7 0
Model D2 (7-factor structure (virtue ethics combined)
.880 .0539 .075 586.80 168 3.49 193.05 7 0
Model D3 (7-factor structure) (virtue of others and act deontology combined)
.922 .0492 .061 439.54 168 2.62 45.79 7 0
Ethical decision making and health care managers | 137
study, had an acceptable fit: CFI=.933, RMSEA= .057, SRMR= .0467, even though
the chi square was significant: χ² (161) = 191.60, p>.001.
Moreover, the a priori eight-factor structure fits the data significantly better than any
of the alternative models (see Table 6.3). A chi-square difference test was calculated
on the differential results from the eight-factor structure and all the other models
including the baseline model, and, due to the fact that all the results were significant
(less than .001), this indicates that the eight-factor structure fits the data better than
any other competing models. This result provides evidence of cross-validation for the
new MEP scale.
Even though the eight-factor structure fits the data better than any of the other
models tested in this paper, some issues were identified with regards to the internal
consistency of some of the eight latent factors. The rule utilitarianism factor shows
relatively low item loading (.41 and .61) and also a low composite reliability (CR)
score of .41. Another factor that will need same improvement is reputational egoism
due to the factor loadings of .74 and .65, and a CR score of .65. The fact that rule
utilitarianism shares a rather high percentage of variance (.754 shown in Table 6.4)
with reputational egoism indicates a need to further develop these items in order to
increase their discriminant capacity, and to develop new items to strengthen the other
factors as well.
Ethical decision making and health care managers | 138
Table 6.4 Correlation, average variance extracted (AVE), and shared variance estimates for Model A
SS1 SS2 SS3 SS4 SS5 SS6 SS7 SS8
SS1 .55 .567 .056 .397 .164 .191 .257 .233
SS2 .321 .69 .134 .754 .242 .228 .340 .342
SS3 .003 .018 .85 .489 .360 .522 .436 .368
SS4 .158 .568 .239 .51 .430 .615 .608 .629
SS5 .027 .058 .130 .185 .87 .711 .568 .490
SS6 .036 .051 .272 .378 .505 .69 .871 .748
SS7 .066 .011 .190 .370 .322 .758 .68 .814
SS8 .040 .110 .130 .400 .240 .56 .662 .78
6.8 General discussion
Table 6.3 presents results from the CFA on a number of different models in order to
ascertain that the eight-factor structure model fits the data better than any other
models.
The purpose of this study has been to develop a psychometrically sound instrument
that measures the ethical principles affecting managerial decision making. The
results from this study support the initial argument that schools of moral philosophy
are multidimensional, and that using them as a single factor (category) does not fit
well with reality, as shown in Table 6.3 (Model C). Even though some results in
Table 6.4 suggest that strong correlations exist between some of the ethical sub-
scales (above .7), the results of CFA suggest that the best fit was the eight-factor
structure model. One example is the strong correlation between virtue ethics and
deontology, a situation that can be explained by the fact that both schools of moral
philosophy follow a non-consequentialist approach to ethics. In other words,
managers would not take into consideration the outcomes of an action, but they
Ethical decision making and health care managers | 139
would rather follow clearly articulated ethical principles or rely on characteristics
traits (virtues) to determine the rightness of an action.
To further explain these correlations, it is important to recall how each of the MEP
sub-scales works in action. A strong correlation (.814) exists between the two
deontological sub-scales, results that can be explained by recalling that the only
difference between them is that an act deontologist relies less on rules to grasp what
must be done in a particular situation and more on conscience, faith, and intuition,
while rule deontologists would judge actions to be right as long as they conform to
some fundamental principle or rule—the golden rule and Kant’s categorical
imperative are good examples. Neither looks at the consequences, but they take a
slightly different cognitive approach to ascertaining their respective duties. Similarly,
the two sub-scales from virtue ethics are strongly correlated (.711) as both sub-scales
start with the idea that good decisions are made by good people, that is, people who
possess virtues (wisdom). Some of those virtues would be individual character traits
that promote personal well-being (virtue of self); others would be character traits that
promote living well with others and caring for others (virtue of others).
Interestingly, the strongest correlation shown (.871) is between virtue of others (care
ethics) and act deontology, a situation that can be explained by the fact that both sub-
scales are strongly related to the extent that deciding the right thing to do is focused
on the individual in a particular context, whether it is predispositions such as
empathy or care (virtue of others), or intuitions about one’s duty in a particular
situation (act deontology). Despite that fact that these strong correlations can be
explained, the literature provides some evidence about the existence of
Ethical decision making and health care managers | 140
multidimensionality of deontology and virtue ethics (Casali, 2007; Ferrell et al.,
2008). Therefore, in order to assess if there is a further simple explanation behind
these strong results—for example, that each of the two schools of moral philosophy
is in fact one-dimensional—two further seven-factor models have been tested and the
results presented in Table 6.3. Results from the two seven-factor models suggest that
the model with the best fit is still the one with eight latent factors, confirming that a
more realistic view can be captured with the multidimensional scales. Also, there is a
strong correlation between two consequentialist sub-scales: reputational egoism and
rule utilitarianism. This correlation can be explained by recalling that this study is
about managerial decision making and, therefore, it is likely that following
organisational rules will be directly linked to protecting organisational reputation. An
interesting point is that there were no negative correlations, which means that scoring
high on one sub-scale does not necessarily decrease the opportunity to score high on
any of the others. This result can be further explained by the fact that the MEP scale
has been administered to managers, and that they were asked to assess the degree of
influence that the different items play when they make a business decision.
Managers, in accepting their positions, agree to maintain a duty of care. In order to
satisfy or discharge that duty of care, they must behave as a ‘reasonable person’
would, taking into account their position, specific skills, knowledge, and experience.
The duty of care requires them to consider the consequences of their actions and
omissions, and to ensure that those acts and omissions do not give rise to a
foreseeable risk of injury to any other person. Because of their duty of care,
managers have to consider a number of factors when making a decision; therefore, it
is expected that they would not be exclusively influenced by a particular sub-scale
but rather they would consider most of them to be of a certain import.
Ethical decision making and health care managers | 141
6.9 Conclusion
In conclusion, it should be reiterated that this study is a maiden effort to develop a
comprehensive scale to measure managerial ethical decision making. The present
study investigated the appropriateness of eight dimensions of the MEP scale for use
in the business ethics literature.
The findings of this study indicate that the eight-factor model appeared to be the best
theoretical construct, suggesting that ethical frameworks are multidimensional
(Model A eight sub-scales). Although some ethical sub-scales were highly correlated
with each other (act and role deontology sub-scales, virtue of others and virtues of
self sub-scales, and virtue of others and act deontology), these eight sub scales still
distinctly measured their own ethical constructs. This implication can be seen by
comparing the results in Table 6.3 of the eight-factor model (Model A) with the
results of the three seven-factor models (Model B1, B2, and B3—many of them were
significantly worse than Model A.
The multidimensional Model A significantly fits the data better than any other of the
models tested (Table 6.3), suggesting that managers do not necessarily subscribe to
one of the major ethical frameworks (egoism, utilitarianism, virtue ethics, or
deontology), but rather they claim to be influenced by particular dimensions within
them, such as economic egoism, reputational egoism, act utilitarianism, rule
utilitarianism, virtue of self, virtue of others, act deontology and rule deontology.
Therefore, these results support the first and third explicit assumptions in this paper.
Each ethical framework has a number of unique principles that can be
operationalised into ethical criteria for managerial decision making. The second
Ethical decision making and health care managers | 142
assumption is also supported. The different schools of moral philosophy can be
treated equally, and, in particular, the eight sub-scales can be operationalised non-
hierarchically.
It is necessary to point out some limitations to this study. Firstly, although
respectable in size, our practitioner sample was limited to health care managers in
Australia. Another limitation of this study is related to the fact that some of the MEP
sub-scales currently have only two items due to the fact that three out of the initial 24
items in the MEP scale were dropped because of a cross loading result. To begin to
address these limitations, future research should explore the reasons for this cross
loading and subsequently modify the items. Secondly, additional studies should be
carried out on the validation of the MEP sub-scales by collecting data across
different industries and countries.
Clearly, developing a new scale is not a quick and easy task; however, this paper has
shown that the MEP scale has great potential to be an appropriate instrument for
assessing the preferences of managers with regards to what they report to be the most
important ethical principles that they draw on in their decision making. The MEP
scale avoids simplistically treating the major ethical frameworks as unidimensional
and categorising managers accordingly; rather, it provides each respondent with the
opportunity to choose between a number of ethical dimensions present in the most
common ethical frameworks (ethical egoism, utilitarianism, virtue ethics, and
deontology). The MEP scale can be used to profile managers based on their ethical
preferences, providing a snapshot—at the individual, group, or organisational level—
of the way in which decision makers interpret ethical challenges. This scale can be
Ethical decision making and health care managers | 143
used in organisations at different levels for different purposes; for example, as a tool
to select people for a particular job that could required a particular ethical propensity
such as following duties (high in rule utilitarian) or empathising with others (high in
care ethics). Another possible application of the MEP scale is as a selective tool for
inclusion in a particular training programme or for the very development of training
programs based on the ethical needs of the people requiring training. Organisations
could also measure potential employees’ values during the hiring process and strive
to choose individuals who ‘fit’ within the ethical climate rather than those whose
beliefs and values differ significantly. A poor ‘fit’ can have very expensive
ramifications for both organisations and employees.
Ethical decision making and health care managers | 144
Chapter 7 The relationship between
managerial ethical profiles and individual,
organisational, and external factors
influencing the ethical decision making of
health care managers in Australia
7.1 Abstract
Whether the community is looking for scapegoats to blame, or seeking more radical
and deeper causes, health care managers are in the firing line whenever there are
woes in the health care sector. The public has a right to question whether ethics have
much influence on the everyday decision making of health care managers. This paper
reports on the findings of empirical research into the influence of ethics and other
factors on the decision making of 441 health care managers in Australia. Results
from this study indicate that health care managers in Australia draw on a range of
ethical frameworks in their everyday decision making, which, in this study, form the
basis of five corresponding MEPs: Knights, Guardian Angels, Duty Followers,
Defenders, and Chameleons.
Results from the study also indicate that the range of individual, organisational, and
external factors influencing decision making can be grouped into three major clusters
or functions. Cross-referencing these functions and other demographic data to the
MEPs provides further analytical insight into each profile’s characteristics. By
summarising existing strengths and weaknesses in managerial ethical decision
Ethical decision making and health care managers | 145
making, identifying these profiles not only can contribute to increasing
organisational knowledge and self-awareness, but also has clear implications for the
design and implementation of ethics education and training in large-scale
organisations such as health care systems.
7.2 Introduction
In the past decade, there have been a number of inquiries worldwide into the health
sector because of alleged mismanagement or individual unethical behaviours. In
Australia, the King Edward Memorial Hospital Douglas Inquiry was established
based on concerns related to the treatment of obstetrics and gynaecological cases at
the Perth-based hospital, the Royal Melbourne Hospital Inquiry was established as a
result of unprofessional behaviours, medication errors, and inappropriate treatment of
patients (Braithwaite et al., 2005; Davies, 2005; Morton, 2005). As a result of these
failures, a number of ‘scapegoats’ or ‘tip of the iceberg’ reasons were found and are
being investigated. In the initial part of the Bundaberg Hospital Commission of
Inquiry (Davies, 2005; Queensland Government, 2006), for example, a few senior
managers were identified as ‘bad apples’ and removed from their duties. However,
upon closer examination, it appears that the barrel may have been just as much a part
of the problem as the apples, a situation that has been referred to as an unhealthy
organisational culture—characterised by a lack of congruence between the
organisational values and behaviours expressed in everyday practice, and between
the shared values of the majority of staff members and the espoused values of the
organisation (Casali & Day, 2010). Whether the community is looking for scapegoats
to blame, or seeking more radical and deeper causes, health care managers are clearly
in the firing line whenever there are woes in the health care sector, and the public has
Ethical decision making and health care managers | 146
a right to question whether ethics have much influence on the everyday decision
making of health care managers.
Chapter 7 reports the findings of empirical research into the influence of ethics and
other factors on the decision making of 441 health care managers in Australia.
Foremost, it is concerned with identifying the variety of ethical frameworks
influencing managerial ethical decision making. Simply using the major schools of
moral philosophy as boxes and allocating respondents into one or the other is not the
most realistic approach (Casali, 2008a; Casali, 2008b; Casali, 2007) as each school
of moral philosophy has a number of dimensions that managers can align themselves
with. As such, ethical considerations are unlikely to influence managers in a vacuum.
The study also identifies a range of other internal and external factors and the
interplay of these with the ethical influences.
Results from this study indicate that, rather than drawing on specific ethical
traditions in their decision making, health care managers in Australia draw on a
range of ethical frameworks in their everyday decision making. This mix of
influences results in five major clusters, which, in this study, form the basis of five
corresponding MEPs: Knights, Guardian Angels, Duty Followers, Defenders and
Chameleons. Results from the study also indicate that the range of individual,
organisational and external factors influencing decision making can be grouped into
three major functions or orientations. Cross referencing these orientations to the
MEPs provides further analytical insight into the characteristics of each profile.
Summarising, as they do, existing strengths and weaknesses in managerial ethical
decision making, identifying these profiles not only can contribute to increasing
Ethical decision making and health care managers | 147
organisational knowledge and self-awareness, but also has clear implications for the
design and implementation of ethics education and training in large scale
organisations such as health care systems.
7.3 Methodology
The primary data for this study was obtained via a self-administered e-mailed
questionnaire. The questionnaires were sent to all of the members of a professional
body that agreed to participate in this study.
7.4 Instrument
The tool used for this study was the MEP questionnaire, which was designed to
capture managerial ethical preferences (Casali, 2009). In total, the MEP
questionnaire (Appendix 1) consists of 52 items (measured by a five-point Likert
Scale: 1=most important and 5=least important) covering a number of factors—
ethical, individual, organisational, and external—influencing managerial ethical
decision making. Out of those 52 items, 24 items were specifically developed to
tease out the importance of ethical factors in managerial ethical decision making, and
the remaining 28 cover the individual, organisational, and external influencing
factors. Content and construct validity were tested in relation to the items
(statements) representing the different dimensions of ethical decision making (Casali,
2009). Content validity was tested by converting the main ideas of the different
schools of moral philosophy, as expressed in the current literature, into operational
statements. With respect to content validity, 14 experts in the field of ethics,
philosophy, and theology were interviewed (Casali, 2009). These 24 items have been
divided into four sets of items, based on their affinity to one of the following schools
Ethical decision making and health care managers | 148
of moral philosophy: egoism, utilitarianism, virtue ethics, and deontology. The six
items used for each of those four categories have been further divided into two
subsets based on the major internal differences within each ethical framework
(Casali, 2009), therefore, eight ethical sub-scales have been created:
SS1 Economic egoism: represents managerial self-interest, particularly in terms
of the role that economic outcomes such as profit and cost reduction play in the
managerial decision-making process.
SS2 Reputational egoism: is a sub-scale that refers to managerial self-interest
pursued not in terms of economic outcomes, but by identifying one’s
organisation as an extension of one’s own interests. Therefore, the manager
would act to protect the organisation’s reputation, and they would protect the
organisation’s reputation, possibly even at the expense of profits.
SS3 Act utilitarianism: encompasses the idea that in order to create the greatest
overall good it is fundamental to evaluate whether the consequences of each
proposed action will create the greatest benefit for the greatest number of
stakeholders.
SS4 Rule utilitarianism expresses the same interest in the greater good, but,
instead of focusing on each separate action, it proposes to establish and follow
those rules which benefit the majority.
SS5 Self virtue: measures the degree of importance attached to individual moral
character as a determinant of good decision making.
SS6 Others virtue: as a particular framework of virtue ethics, concerns living
well with others, promoting social well-being, and would include what is referred
to as care ethics.
SS7 Act deontology: measures the degree of importance attached to doing the
right thing or fulfilling one’s duty in a particular situation. Moral rules can have
exceptions, particularly when moral duties conflict. The rightness of an act is not
determined by the ruthless application of a moral principle but by determining
what duty is demanded in the particular situation.
SS8 Rule deontology: focuses on fulfilling universal duties, such as the Golden
Rule, or acting according to universal principles (e.g. justice, not harming others,
doing good, and respecting autonomy) in all situations.
Ethical decision making and health care managers | 149
7.5 Sample characteristics
To investigate the managerial ethical preferences of health care managers in
Australia, members of an Australian health care managers’ association were
approached by e-mail to participate in the study. A link was provided to an online
questionnaire. From the association’s total membership of 2,473, a sample of 441
usable questionnaires was collected, providing a 17% response rate. Of the sample,
244 (55.3%) were female and 197 (44.7%) were male. The mean age was 44 years
(SD=.921). Almost half (43.8%) of the people in the sample were managers; 16.1%
were senior managers; 15%, corporate governance; 13.2%, supervisors; and 12%
were consultants. More than two-thirds (79.4%) of the total sample held postgraduate
degrees of some kind, and 20.6% had an undergraduate degree or less. The majority
(62.1%) of individuals in the sample worked for the government, 28.3% for the
private sector, and 9.5% for religious organisations. In terms of work experience,
31% of those sampled had 3 years or less experience, 49% had between 4 and 10
years of experience, and 20% had 11 or more years’ experience. Of the respondents,
268 (61%)—the largest group—were administrative staff, while 118 (27%) were
medical staff (doctors and nurses), and 55 (12%) were allied health staff.
7.6 Procedure
Chapter 7 applies a procedure similar to that used in the preliminary development of
the MEP scale as an instrument for investigating managerial ethical decision making;
in particular, the development of MEPs (Casali, 2008b). This previous study
gathered the data by administering the MEP questionnaire to a small sample of
academics and students (n=41) and small business managers (n=41), and then
computing the results of the 24 ethical items into the eight ethical sub-scales as
Ethical decision making and health care managers | 150
suggested by Casali (2007). Due to the small size of the sample, once the computed
results of the eight sub-scales were created, an HCA was performed to ascertain how
many clusters (MEPs) could have been developed (Casali, 2008b). Preliminary
results indicate that there were five consistent MEPs; although, with the small
business managers, only four of the five MEPs were confirmed—one cluster was
missing (Casali, 2008b). As in the previous study, the results from the 24 ethical
items of the MEP questionnaire have been computed into eight ethical sub-scales and
then clustered. However, due to the larger sample (n=441), a two-step cluster method
was used since hierarchical and K-means clustering, as used in the preliminary study,
does not scale efficiently when “n” is very large. A further limitation of the previous
study was its focus on ethical factors and the lack of analysis of individual,
organisational, and external factors that Casali (2008b) has argued are important
influences on managerial ethical decision making. Therefore, this study will analyse
the remaining 28 items related to those factors by using discriminant analysis, and
then look for significant correlations between the five MEPs (results of the two-step
cluster analysis) and the functions (results from the discriminant analysis) to further
analyse the MEPs of health care managers in Australia.
7.7 Analysis
The data collected from surveying the health care managers has been analysed in
several ways. The 24 items reflecting the ethical factors were first computed based
on the eight ethical sub-scales (Casali, 2008a), and then a two-step cluster analysis
was performed. It is well known among researchers that this clustering technique
usually leads to two clusters, that is, results that represent the most different possible
clusters. To overcome this limitation, in this study, five desired clusters were used
Ethical decision making and health care managers | 151
based on results from the previous exploratory research using the MEP scale as an
instrument to profile (Casali, 2008b). To further support the five clusters solution,
multivariate analysis (MANOVA), analysis of variance (ANOVA), and Scheffe tests
of differences in groups means were also conducted. The remaining 28 items
reflecting individual, organisational, and external factors have been analysed using
discriminant analysis.
7.8 Results
This section shows the results from the two-step cluster analysis based on the eight
ethical sub-scales (Section 7.8.1), and the results of the discriminant analysis of the
individual, organisational, and external factors and how they relate to the clusters
from the two steps cluster analysis (Section 7.8.2).
7.8.1 Two-step cluster analysis results
Results of the two-step cluster analysis performed on five desired clusters indicated
the following results, as shown in Table 7.1.
Cluster 1, which represents 28% (121) of the sample, performed as follows in
relation to the eight ethical sub-scales: 1.8 on economic egoism, 1.25 on reputational
egoism, 1.4 on act utilitarian, 1 on rule utilitarian, 1 on virtue of self, 1.25 on virtue
of others, 1.4 on act deontology, and 1.1 on rule deontology.
Cluster 2 (13% or 60 people), 2.8 on economic egoism, 2.25 on reputational egoism,
1.4 on act utilitarian, 1.15 on rule utilitarian, 1.2 on virtue of self, 1.25 on virtue of
others, 1.8 on act deontology, and 1.25 on rule deontology.
Ethical decision making and health care managers | 152
Cluster 3 (17% or 74 people): 2.1 on economic egoism, 1.6 on reputational egoism,
1.8 on act utilitarian, 1.2 on rule utilitarian, 2 on virtue of self, 1.5 on virtue of others,
1.6 on act deontology, and 1.2 on rule deontology.
Cluster 4 (26% or 118 people): 2.3 on economic egoism, 1.7 on reputational egoism,
2 on act utilitarian, 1.2 on rule utilitarian, 1.8 on virtue of self, 1.8 on virtue of others,
2 on act deontology, and 1.8 on rule deontology.
Cluster 5 (16% or 68 people): 2.8 on economic egoism, 2.3 on reputational egoism,
2.6 on act utilitarian, 1.9 on rule utilitarian, 1.9 on virtue of self, 2.2 on virtue of
others, 2.5 on act deontology, and 2.2 on rule deontology.
Manova showed that the five clusters were significantly different (F= 38.231, p <
0.001). Variations in dimensions of the ethical sub-scales among the five clusters
were gleaned from ANOVA, as summarised in Table 7.3. Scheffe tests also
highlighted the distinguishing qualities of the five managerial ethical profiles. In
reviewing the profiles of the five clusters (Table 7.1), the reader should not that
because the number and content of clusters were inseparable from the classification
criteria used, the results of ANOVA were presented only to illustrate where the
greatest differences existed among the clusters.
Ethical decision making and health care managers | 153
Table 7.1 Standardised means of the five MEPs: results of the two-step cluster, ANOVA, and Scheffe
Ethical
Sub-
Scales **
Managerial Ethical Profiles
Knight (1) 121 (28%)
Guardian Angel (2) 60 (13%)
Duty Follower
(3) 74 (17%)
Defender (4)
118 (26%)
Chameleon (5)
68 (16%)
Scheffe Results F
SS1 1.8388 2.7667 2.0777 2.2945 2.8382 1>2; 1>4; 1>5; 3>2; 3>4:
4>2; 4>5
52.085*
SS2 1.1860 2.2250 1.5811 1.6356 2.2794 1>2; 1>3; 1>4; 1>5; 3>2;
3>5; 4>2; 4>5
71.230*
SS3 1.4187 1.4167 1.6802 2.0452 2.5098 1>3; 1>4; 1>5; 2>3; 2>4;
2>5; 3>4; 3>5; 4>5
70.183*
SS4 1.0124 1.1501 1.0541 1.1525 1.7982 1>5; 2>5; 3>5; 4>5 66.533*
SS5 1.0372 2.1486 2.1486 1.9195 2.3162 1>3; 1>4; 1>5; 2>3; 2>4;
3>5; 4>3; 4>5
128.776*
SS6 1.2541 1.5034 1.5034 2.0318 2.3051 1>3; 1>4; 1>5; 2>3; 2>4;
2>5; 3>4; 3>5; 4>5
126.694*
SS7 1.4793 1.5946 1.5946 2.3432 2.5294 1>4;1>5; 2>4; 2>5; 3>4;
3>5
73.211*
SS8 1.0806 1.1655 1.1655 1.7225 2.0551 1>4; 1>5; 2>4; 2>5; 3>4;
3>5; 4>5
148.684*
** SS1 Economic Egoism, SS2 Reputational Egoism, SS3 Act Utilitarian, SS4 Rule Utilitarian, SS5 Virtue of Self, SS6 Virtue of Other, SS7 Act Deontology, and SS8 Rule Deontology *p<0.001
7.8.2 Discriminant analysis results
The importance of the discriminant function is analysed through Wilks’ Lambda.
This measures the proportion of the total variance in the discriminant scores not
explained by differences among groups. The chi-square (2) for the mentioned value
was calculated and it is possible to determine the level of significance on this basis.
Table 7.2 shows the main parameters of the nine discriminant functions. In all cases,
only one discriminant function has been estimated. It can be observed that the
Ethical decision making and health care managers | 154
discriminant functions 1, 2, and 3 are sufficiently significant, with values of p <0.05;
however, function 4 is not significant (see Table 7.2).
Table 7.2 Discriminant analysis
Discriminant functions
Function 1 Function 2 Function3 Function 4
L de Wilks .409 .714 .847 .940
Chi-square 378.694 142.738 70.394 26.049
Significance .000 .000 .046 .405
Function in group centroid
Cluster 1
Knight
-1.145 -.101 .255 -.116
Cluster 2
Guardian angel
-.192 .994 -.153 .213
Cluster 3
Duty Follower
-.040 -.237 -.664 -.195
Cluster 4
Defender
.477 -.351 .067 .328
Cluster 5
Chameleon
1.422 .171 .288 -.338
7.9 Discussion
7.9.1 Managerial ethical profiles
This section will first discuss the results of the cluster analysis in relation to the
MEPs, and subsequently correlate them with the results of the discriminant analysis
in order to enrich the profiles and their characteristics. The results from the two-step
cluster analysis confirm the existence of five MEPs. In general, both studies (small
and large samples) have found that a five-cluster structure exhibits high internal
homogeneity, which means that each individual included in a particular cluster
displays very strong similarities in terms of their ethical preferences in decision
making. At the same time, both studies have shown that each cluster exhibits a high
external heterogeneity in terms of keeping consistent, significant differences between
Ethical decision making and health care managers | 155
each cluster, and, in particular, that each cluster represents a unique mix of
preferences with respect to the eight ethical sub-scales. In developing these profiles,
a universal or strictly mathematical formula was not used, but each cluster has been
analysed individually, and inferences have been based on examination of the internal
relations between the scores from the eight sub-scales.
Figure 7.1 The Knight profile
Cluster 1 comprises the overall score for all of the eight sub-scales between 1 and 1.8
(see Figure 7.1), which in this case can be seen as a manager’s very strong
predisposition to take all of the ethical principles into consideration. A similar
combination of scores was found in a previous study and the cluster was called the
Knight profile (Casali, 2008b). These managers consistently rate all of the eight
ethical sub-scales highly, endeavour to maximise theirs and their organisation’s
values, keep economic factors in the picture, and consider the impact of decisions on
all stakeholders (Casali, 2008b). Managers who exhibit this profile are ethical
pluralists, and they will take into consideration all of the individual moral principles
by putting them into a global scenario (Casali, 2008b). A possible downside of being
the only profile representing ethical pluralism is that the knight might have too high
Ethical decision making and health care managers | 156
an expectation about their leaders’ and their organisation’s espoused values and
therefore can be easily disappointed (Minkes, Small, & Chatterjee, 1999).
Figure 7.2 The Guardian Angel profile
Overall, Cluster 2 shows less focus on those sub-scales that are directly related to the
organisation (See Figure 7.2), such as economic and reputational issues (computed
means 2.8 and 2.25), but display a strong emphasis on the other six sub-scales
(computed means between 1.2 and 1.8). A cluster with this result can be called
Guardian Angels—managers who not only make sure that they conform to rules, but
who ensure that the dignity of others is maintained by also keeping an eye on the
outcomes (Casali, 2008b). Guardian angels are strongly committed to fulfilling the
obligations that go with a public or professional role and, therefore, they feel a duty
to consider the consequences of their decisions and to treat others fairly. They obey
rules but at the same time they use their wisdom to consider the impact on others of
so doing. A risk with this profile is that the potential conflict between the Guardian
Angel’s strong commitment to duty and their concern for others may lead to
inconsistent responses, and also to costly outcomes due to low influence of economic
factors.
Ethical decision making and health care managers | 157
Figure 7.3 The Duty Follower profile
To some extent, Cluster 3, looks similar to the Guardian Angel, as they also score
lower on the first two sub-scales and higher on the rest; however, this cluster is
characterised by three very strong sub-scales; rule utilitarian, others virtue (care
ethics) and rule deontology (see Figure 7.3). In the preliminary study, similar scores
were exhibited by the profile called the Duty Follower. It is characterised by a strong
belief that rules and duties are the most important factors in managerial ethical
decision making (Casali, 2008b). Managers with this profile are usually focused
more on doing the right thing, rather than the consequences. They tend to have a
more absolutistic view of morality, and they are very strong advocates of universal
duties such as not lying to or harming others. Those exhibiting this profile have high
moral standards in terms of fairness and justice. However, the risk is that Guardian
Angels will achieve this at the expense of efficiency or flexibility due to the low
influence of economic and reputational factors (Casali, 2008b).
Ethical decision making and health care managers | 158
Figure 7.4 The Defender profile
Cluster 4, on the other hand is characterised by two main sub-scales: rule utilitarian
and reputational egoism (see Figure 7.4). This profile has been named the Defender.
Managers in this cluster are very loyal to the organisation and will vigorously protect
its reputation (Casali, 2008b). Honour and reputation are important at both the
personal and organisational levels, and maintaining a good opinion about oneself and
one’s organisation can be more important than the bottom line. The Defender would
spend more time weighing up what is good versus what is good for the organisation.
These individuals are extremely important for and organisation because they are the
most loyal and are less likely to undermine its goals by pursuing either self-interest
or the interest of those outside the company (Casali, 2008b). However, the excessive
loyalty of the Defender is not always helpful. There is a significant risk that they
might be willing to engage in illegal or unethical actions in the name of enhancing or
protecting the organisation’s reputation. Like a defender in a soccer team, they would
accept the penalty of taking down an opponent in front of goal and perhaps even risk
a personal send off, for the good of the team. A recent corporate example would be
the behaviour of some employees of the Australian Wheat Board. Its former
Ethical decision making and health care managers | 159
chairman, when accused of bribe and breaching a number of UN oil-for-food
sanctions, said in a statement issued by his lawyers: ‘I emphatically deny that I acted
in any manner other than in the best interest of AWB and its shareholders.’
(McMahon, 2007).
Figure 7.5 The Chameleon profile
In one way, those in Cluster 5 are similar to the Knights; their individual scores for
each of the eight sub-scales are evenly distributed. However, the overall scores are
lower than those of the Knights (see Figure 7.5). This profile has been dubbed the
Chameleon. Just like the reptile adapts its skin colour to fit in with its surrounds,
these managers draw on each different ethical framework, deciding which is the most
appropriate for a particular situation (Casali, 2008b). Arguably, the Chameleons have
a realistic view of morality; they do not rigidly hold a particular position but assess
the context first and then apply the ethical framework that is most appropriate to that
particular situation. While this profile is more flexible than the Duty Follower, there
is also a risk that all of this flexibility could simply encourage decision makers to
blend in with the prevailing culture (‘when in Rome, do as the Romans do’) rather
than engaging with it proactively (Casali, 2008b). At best they might be weak
pluralists; at worst, they are moral relativists.
Ethical decision making and health care managers | 160
7.9.2 Managerial ethical orientations
From the results of the discriminant analysis, only three of the four functions were
significant; that is, only the first three functions can help to discriminate between the
five MEPs (see Table 7.1). Function 1 is the biggest out of the three, with 15 items
out of the 26 analysed, varying from emphasising the importance of organisational
codes of ethics to personal values, and from accounting for the environment to being
guided by self-experience and professional experience. Due to both the large number
of influences that are correlated to this function, and to their range—some are
directly related to the individual, others to the organisation and to external factors—
this function could be seen as promoting a universal orientation in decision making
by significantly taking into consideration a large number of stakeholders and
competing values. It can be contrasted against Function 2, where the influences are
more narrowly restricted to external factors such as mission statements, competition
with other organisations, or purely economic goals. In this function, managerial
ethical decision making aligns externally with the mission statement of the
organisation, attaining good economic outcomes, and creating or maintaining a
competitive advantage. Function 3 has two out of three items that are negatively
correlated to it: decision making by personal judgment and pre-conventional
Kohlberg cognitive moral development stage, and one item that is positively
correlated to other professional experience. Therefore, this function summarises a
role-model orientation in managerial ethical decision making: a tendency to be more
influenced by concrete others. Rather than individual managers strongly relying on
their own capabilities, knowledge, and values, decision-makers functioning in this
way are strongly affected by role models or what experts have to say.
Ethical decision making and health care managers | 161
To further the analysis of the MEP scale in the health care sector in Australia, it is
important to assess the relationship between the five MEPs and the three functions
(Table 7.2). As expected, Function 1, which promotes universality and stakeholder
approach to managerial ethical decision making, is strongly correlated to the Knight
profile and uncorrelated to the Chameleon profile. The other three profiles are
somewhere in the middle between the two extremes (Knight and Chameleon). Once
again, as expected, Function 2, which relies heavily on the mission statement and
economic competition, is positively correlated to the Defender profile and to some
extent to the Duty Follower, but is weakly correlated to the Knight and Chameleon
profiles, and negatively correlated to the Guardian Angel profile. With respect to
Function 3, the Duty Followers are the most positively influenced by experts or
referent people in their decision-making process, while the least affected are equally
Knights and Chameleons.
7.10 Conclusion
As previously discussed, individual preferences with respect to ethical frameworks
are not easy to identify, especially if one rejects the a priori assumption that
respondents have a preference for only one ethical approach. A measurement
instrument is needed that reflects the multidimensional nature of respondents’
preferences, that is, their perceptions that a number of ethical frameworks may be
important to managerial ethical decision making. As described in this chapter, this
element has been well captured by using the MEP scale. First, using the instrument,
the existence of five prominent managerial ethical profiles (Knights, Duty Followers,
Guardian Angels, Defenders, and Chameleons) has been ascertained and confirmed,
and their distinctive features, including their relative strengths and weaknesses, have
Ethical decision making and health care managers | 162
been described. Second, the current understanding of the MEP scale has been
furthered by examining the correlation between these MEPs and a number of
individual, organisational and external factors influencing decision making in the
health care sector in Australia. In relation to the first purpose, this study has
confirmed the existence of five MEPs with similar characteristics to those identified
in previous research (Casali, 2008b). Second, the current research has identified the
particular pattern of these profiles among a significant sample of the health care
managers in Australia. It is interesting to note, for example, that the profile of one
out of two Australian health care managers surveyed is either a Knight or a Defender
(aggregate 49%). Both Knights and Defenders are highly focused on maximising
outcomes for the good for the organisation, though it could be said that the Knights
tend to do this with an eye on the interests of the community as a whole, while the
Defenders are more likely to treat the reputation of their organisation as an extension
of their own. The prominence of Knights can be partly explained by the fact that a
larger number of Knights in the sample were managers in the private sector. The
Knights’ cohort also contained a significantly higher number of managers with 11
years or more of professional experience in their current role, which counted for 20%
of the total sample (89 managers). Given that managers with the Chameleon profile
tended to be the least experienced, it can reasonably be inferred that strong
commitment to using a variety of ethical frameworks in managerial ethical decision
making (strong pluralism) is a product of accumulated experience and reflection and
that the flexibility of the Chameleon profile reflects a weak pluralism or ethical
relativism derived from a lack of experience or a desire to please and conform.
Ethical decision making and health care managers | 163
Chapter 7 aimed to measure and profile the multidimensional influence of ethical
frameworks on managerial decision makers in the Australian health care sector,
while noting at the same time a range of other factors—individual, organisational,
and external—also influencing their decision making. The confirmation of a stable
set of profiles across two studies suggests some useful outcomes for both practice
and research. There is obvious practical potential for the thoughtful use of the MEP
scale as an instrument to help managers increase awareness of their own managerial
ethical profile. The MEP scale can also help an organisation to assess its ethical
strengths and weaknesses, based on the relative strength of the different profiles
within the organisation.
Ethical decision making and health care managers | 164
Chapter 8 Conclusion
8.1 Introduction
Incidents like that involving Dr Jayant Patel at the Bundaberg Base Hospital have
increased the degree of public scrutiny on the health care industry in Australia.
Managers deal with ethical issues all the time; however, in the case of health care
managers, a mismanaged situation can adversely affect patients and their families,
employees and their families, and the wider community. In Australia, despite the fact
that in most cases codes of ethics, strong espoused organisational values, and also
strong individual staff values are in place, mismanagement of ethical issues still
occurs (Casali & Day, 2010). Increasing the ethical decision-making capacity of
managers remains at the forefront of addressing this situation. This thesis has used
profiling techniques based on an analysis of the factors influencing ethical decision
making to unlock the black box of managerial ethical decision making of health care
managers in Australia. These managerial profiles can be used to increase individual
and organisational knowledge about the diverse range of ethical decision-making
styles of managers in an organisation and to adjust organisational practice
accordingly.
8.2 Key findings
Based on the factors (ethical, individual, organisational, and external) influencing
their decision making, the ethical outlook of Australian health care managers can by
summarised according to five MEPs: Knight, Duty Follower, Guardian Angel,
Ethical decision making and health care managers | 165
Defender, and the Chameleon (Table 8.1). The five profiles differ primarily in the
degree to which respondents’ decision-making process is influenced by the ethical,
individual, organisational, and external factors.
Table 8.1 MEPs and related scores on ethical sub-scales of health care managers in Australia.
Up arrow=high influence; down arrow= low influence; horizontal arrow= moderate influence
The first MEP is the Knight (n=121), which is strongly influenced by all of the
different ethical principles: a result that is in line with an ethical position known as
ethical pluralism (Hinman, 2007). In contrast to the Knight, the Chameleon profile
(n=68) is characterised by the overall low influence of the different ethical principles.
This profile can be seen as an example of ethical relativism due to the fact that
managers are equally weakly influenced by all of the ethical principles. This is a
potential indication that they do not hold any particular ethical principle to be
superior to another, and that they switch between them as they see it fit or based on
Knight Guardian Angel
Duty follower
Defender Chameleon
Economic Egoism
Reputational Egoism
Act Utilitarian
Rule Utilitarian
Self Virtues
Others Virtues
Act Deontology
Rule Deontology
Ethical decision making and health care managers | 166
the circumstances (Hinman, 2007). The last three profiles better represent ethical
absolutism as they hold some principles to be much higher than others. It is
important to distinguish between ethical relativism and ethical absolutism. For
absolutists, many things that are different from their values are wrong; however, for
relativists, nothing is wrong but simply different (Taft & White, 2007). The
difference between these three profiles is the ethical principles that are deemed to be
the most important. The Duty Follower profile (n=74) upholds rule deontology,
others virtue (care ethics), and rule utilitarianism as the most important principles
when making a decision, and are less concerned with economic and reputational
values. This particular combination of ethical principles suggests that managers with
this profile follow duties, regulations, and procedures, perhaps because they think
that this is the best way to care and protect others. The Guardian Angel profile
(n=60), on the other hand, seems to be equally influenced by the ethics of duty
(deontology) and by the ethics of virtues (virtue ethics), but at the same time follows
those rules that can benefit the majority. Finally, the Defender profile (n=118)
supports the idea that acting or following more universal rules is extremely
important, but protecting the organisational reputation is paramount.
In order to further explain the five MEPs, the other influencing factors—individual,
organisational, and external—were then analysed by using discriminant function
analysis (Chapter 7). The results of the discriminant function analysis on the items
(28 overall) that relate to these three factors (Appendix 1) yielded three statistically
significant functions able to discriminate between the five MEPs. Function is a
technical term commonly used when referring to the results of a discriminant
function analysis, but in this study they describe either a general inclination to be
Ethical decision making and health care managers | 167
more or less oriented towards the different influencing factors. We will, therefore,
refer to them as orientations.
The first orientation has been named the universal orientation. It promotes a
universal perspective in decision making by taking into consideration a large number
of factors (16 out of 28 items) influencing ethical decision making, drawn from each
of the three categories of influencing factors (individual, organisational, and
external). This orientation can be explained as the manager’s propensity to take into
consideration a number of stakeholders. They understand that responsible
management is a social-relational and ethical phenomenon that occurs in social
processes of interaction (Maak & Pless, 2006, p. 99). The second orientation has
been named the external orientation. It emphasises the importance that being in line
with the mission statement of the organisation, attaining good economical outcomes,
and creating or maintaining a competitive advantage has in managerial decision-
making processes.
The third orientation has been named the role model orientation due to the fact that it
summarises a tendency to be guided by expert or referent others rather than one’s
own instincts. Table 8.2 shows the correlation between the five MEPs and the three
orientations. It is possible to see that the strength of correlation between the three
orientations and each of the MEPs has been represented by the size of the semicircle
on each side of the triangles shown below.
Ethical decision making and health care managers | 168
Table 8.2 Correlation between the five managerial ethical profiles and the three orientations
Knight Guardian Angel
Duty Follower
Defender Chameleon
Universal Orientation
High Moderate Moderate Low Low
External orientation
Moderate Low Moderate Moderate/high Low
Role model Orientation
Low Moderate High Moderate Low
The Knight profile correlates most with the universal orientation, as it promotes
universality and a stakeholder approach to managerial
decision making; is very least correlated with the role
model orientation; and is only moderately correlated
with external orientation. This pattern of correlation
between the Knight and the three different orientations
can be explained by reiterating the fact that managers in
this profile have scored very high on all of the eight sub-scales, suggesting that they
would not only give high regard to all of the ethical principles but that they would
take a large number of the other influencing factors into consideration as well. Based
on this definition of the Knight, it is possible to argue that they would not simply
make a decision based only on the opinion of a leader or an expert (role model
orientation); they would take a more holistic view of the situation.
The Guardian Angel, on the other hand, is moderately
influenced by both universal and role model orientations and
least influenced by the external orientation. This pattern of
correlation between the three orientations and the Guardian
Angel profile, in addition to what is already known of ethical
Figure 8.1 Knight orientation
Figure 8.2 Guardian Angel orientation
Ethical decision making and health care managers | 169
preferences, suggests that managers in this profile are strongly influenced by rules
and duties that promote fairness, equality, and respecting the dignity of others.
The Duty Follower profile is highly correlated to the role
model orientation and only moderately to the other two.
This information would confirm the fact that the managers
in this profile are looking for guidelines and clearly
established principles when making a decision, both from
written and formal rules or from the experts. It has been suggested that adhering to
experts’ or leaders’ instructions and organisational regulations can be seen as a
strategy to ‘play on the safe side’ or ‘work by the book’ (Kark & Dijk, 2007, p. 517).
Therefore, it is not surprising that this profile is the highest correlated to the role
model orientation.
The Defender profile is correlated highly to external
orientation, moderately to role model orientation, and least
to universal orientation. It has already being argued that
this profile is strongly influenced by factors that are
closely related to protecting organisational reputation. It
has also been argued that there is a strong relationship between organisational
reputation and performance (Ang & Wight, 2009). In addition, managers in this
profile are strongly influenced by external factors such as competition, economics,
and following the mission statement, because these factors have a direct link to
organisational reputation. Therefore, being a leader in a particular industry suggests
Figure 8.3 Duty Follower orientation
Figure 8.4 Defender orientation
Ethical decision making and health care managers | 170
that a particular firm has developed a competitive advantage against its competitors,
a position that certainly would improve its organisational reputation. Moreover, the
aim of a mission statement is to introduce and promote the organisation to the public.
Therefore any gap between the values and behaviours promoted by the mission
statement and the practice of that particular firm could most certainly foster a bad
public opinion about that firm or low organisational reputation.
The Chameleon profile was not strongly influenced by any of the ethical
frameworks. This profile also shows low correlation with each
of the three orientations, confirming the idea that managers in
this profile have not yet committed themselves to a particular
ethical practice, that they are adaptable.
Two principal conclusions can be drawn from the results of this study. Firstly, the
five MEPs summarise a large number of ethical, individual, organisational, and
external factors that influence health care managers in Australia. The use of these
profiles can potentially simplify the analysis of both practical and theoretical
organisational issues concerning ethics and make it easier to focus on key aspects.
Secondly, Australian health care managers are characterised by the two most
prominent MEPs: the Knight (26%) and the Defender (23%), which may
significantly influence the overall behaviour of the sector—conditioning the
responses of health care workers to issues with important ethical components.
Figure 8.5 The Chameleon profile
Ethical decision making and health care managers | 171
8.3 Significance and practical application
This research has developed MEPs based on reliable and valid measures of factors
influencing ethical decision making in the health care context in Australia. These
MEPs were conceptualised based on three streams of literature—factors influencing
ethical decision making, current tools to measure ethical decision making, and
profiling techniques. This research contributes to the current knowledge in these
three areas and also has practical implications for health care managers and their
organisations.
8.3.1 Contribution to the current knowledge of factors influencing ethical decision making.
This thesis has developed an evidence-based taxonomy grounded in a critical
analysis of more than 40 years of research in this area (Chapter 3), which has
established four categories based on the nature of the influencing factors: ethical,
individual, organisational, and external. This is the first time that a large number of
factors influencing ethical decision making have been collected and presented as a
framework to be used as a basis for future research. The significant contribution of
this study is based on applying the evidence-based taxonomy to the concept of
profiling managers. As a result, this study broadens the ethical decision-making
concept to investigate the degree of influence that a large number of important
factors have on health care managers in Australia.
Ethical decision making and health care managers | 172
8.3.2 Contribution to the current knowledge of tools that measure ethical decision making in organisations
Tools that are currently used extensively to measure ethical decision making are the
Defining Issue Test (DIT) by Rest et al. (1997), the Managerial Judgment Test (MJT)
by Lind (1978), and the Managerial Value Profile by Sashkin et al. (1997). All of
these tools assume that the schools of moral philosophy are unidimensional
constructs and that people belong to only one of them. For example, the Managerial
Value Profile by Sashkin et al. (1997) allocates respondents to one of three schools
of moral philosophy: utilitarianism, individual rights (deontology), and social justice
(Zgheib, 2005). This thesis has shown that schools of moral philosophy are
multidimensional in nature, and that people are influenced by them in different ways.
The MEP scale has provided empirical evidence that using sub-scales of the main
schools of moral philosophy (ethical egoism, utilitarianism, virtue ethics, and
deontology) provides a better description of the differences in ethical styles of
managers (Chapter 6).
8.3.3 Contribution to the current knowledge of profiling in business
Profiling techniques have being extensively used in business to help organisations on
a number of different occasions and for various purposes. For example, profiling
techniques have been used to profile consumers based on different characteristics
such as their decision-making styles (Sproles & Kendall, 2005), their level of need
for information retrieval (Fan, Gordon, & Pathak, 2006), and their motivation when
purchasing via online auctions (Hou & Elliot, 2010). However, this is the first time
that profiling techniques have been used in conjunction with factors influencing
ethical decision making to investigate health care managers. Five significant profiles
Ethical decision making and health care managers | 173
have been identified as a result of using profiling techniques and the proposed
evidence-based taxonomy of factors influencing ethical decision making (Chapter 3).
This research has practical implications not only for health care organisations but for
a wide range of organisations. It is applicable in a number of areas such as
supporting effective ethics programs, improving recruitment and training, and
building team effectiveness based on the knowledge of managerial ethical decision
making that is supported in this thesis.
Finigan and Theriault (2006) have suggested that the effectiveness of ethics
programs (code of ethics and ethical training) are instrumental to personal value
systems and the way that those codes have been interpreted and applied when facing
ethical dilemmas. Managerial ethical profiles can increase the success of ethical
regimes, such as codes of ethics or codes of conducts, by identifying and grouping
employees that share a particular MEP, and tailoring ethics training and internal
communication in ways that will build on the existing strengths of the various ethical
profiles. For example, if the number of Duty Followers in an organisation is
significant higher than any other profiles, then that organisation will need to make
sure that managers and experts are good ambassadors of the organisation’s espoused
values in order to provide staff with good role models to imitate and follow.
Therefore, in this particular case, the organisation should identify the people that are
recognised as role models within the organisation and train them on the mission
statement, vision, espoused values, and policies and procedures.
Ethical decision making and health care managers | 174
Organisations can use the MEP scale as a recruitment tool to support managers to
choose the right person for the job. The health care industry, for example, is facing a
great challenge in recruiting and retaining staff due to the current skills shortage
(Collins, 2007). Therefore, employing the right person and retaining them is vital in
this industry. Laabs (1999) referred to ‘personality fit’ as the degree of fit between
the candidate and the organisation. It has been suggested that to better understand a
job candidate, and, more importantly, their fit with the organisation, depends on the
degree of knowledge that an organisation has on what the person has done (résumé)
and who the person is (Laabs, 1999). A number of behavioural tests have been used
in recruitment for many years, but the MEP scale has a unique capacity to uncover
the MEPs of candidates. Despite the fact that this study suggests that all five MEPs
are equally valid, they could be strategically allocated within the different levels and
areas of an organisation. In a more specific area, the MEP scale can be used as a
valuable instrument to create a diverse and well-balanced board of management. A
strategically recruited group of directors is paramount for a good performance of any
board (Shultz, 2003). There is evidence that supporting diversity in boards of
directors can positively impact the breadth of perspective and the degree of
innovation in making decisions (Van Der Walt, Ingley, Shergill, & Townsend, 2006).
Therefore, making sure that board members are not only chosen for their skills and
technical knowledge, but also based on their MEPs can positively affect the way that
boards make decisions.
The MEP scale developed in this research can be used to better understand individual
managers and build strategies to improve their ethical decision-making capabilities.
Training can be tailored around these five profiles. For example, Duty Follower
Ethical decision making and health care managers | 175
managers might require training that provides strong reference to laws, codes,
regulations, and procedures, while Defender managers might need to see the link
between their skills and the benefit for the organisation’s reputation. Also, the MEP
scale can be used to develop role-play exercises to show how people would approach
decision making according to their profiles and other influencing factors. In this case,
it would be extremely beneficial for managers to see, first hand, snapshots of
common situations in business—such as applying a code of ethics to a particular
situation—and to learn how people would react based on whether they were
Chameleons, Defenders, Duty Followers, Guardians, or Knights.
8.4 Limitations of the study and directions for future research
While the MEPs developed in this study have suggested useful and significant
insights into factors that influence health care managers in Australia, further research
is required to overcome a number of limitations in at least three main areas: (a)
continuing development and refinement of the MEP scale, (b) exploring the extent to
which the MEPs can be applied, both to organisations beyond the health care sector
and in different countries, and (c) examining the relationship between an
organisation’s ethical position and that of the outside community.
8.4.1 Continuing development and refinement of the MEP scale
Although this thesis has provided empirical evidence about the eight ethical sub-
scales of the MEP scale by using confirmatory factors analysis (Chapter 6), there is
room for improvement. Some of the MEP sub-scales currently have only two items
due to the fact that 3 out of the initial 24 items in the MEP scale were dropped
Ethical decision making and health care managers | 176
because of cross loading results (Chapter 6). To begin to address this limitation,
future research could explore the reasons for this cross loading and consequently
modify these items (DeVellis, 2003). In addition to modifying these three items,
more items might be developed to strengthen the other sub-scales.
8.4.2 Exploring the extent to which the MEPs can be applied
The MEP scale has been tested only on health care managers (Chapter 7). In order to
further validate the five profiles that have been discovered and discussed in this
thesis, it will be necessary to administer the MEP scale in different industries and in
different countries and see if the five MEPs are universal or if they are a more
contextual (industry-based).
In particular, the relationship between the orientations and the MEPs remains
untested beyond the health care sample used for the main study. Further exploration
of relationships between the MEPs and the orientations could be based on
investigating possible links between the results of the self-reported data (MEPs and
orientations) and actual behaviours of managers. Like the Myers-Briggs Personality
profiles, MEPs could be tested in relation to a team’s effectiveness by considering
the information of each team member’s MEP (Varsel, Adams, Pridie, & Ruiz Ulloa,
2004). The MEP scale could be administered to each member of different teams in
order to ascertain their individual MEP. Each team could then be asked to perform a
particular task or project before using the Team Effectiveness Questionnaire (TEQ)
to see if there is any particular correlation to the mix of profiles and team
effectiveness (Varsel, Adams, Pridie, & Ruiz Ulloa, 2004). Perhaps one way to move
forward might be to start with health care managers as the MEPs have been created
Ethical decision making and health care managers | 177
and validated in this particular industry and are therefore able to create more
significant and valid results.
8.4.3 Examining the relationship between an organisation’s ethical position and that of the outside community
Finally, more study is required of the relationship between the MEPs within an
organisation and those of the community. For example, a Defender profile may be
counterproductive if the community regards the activities of the organisation as
ethically indefensible. When an organisation is in this position, it is important that
there be diversity at the board level because independent board members may be able
to override self-destructive herd instincts among insiders whose team mentality is
overdeveloped. Toyota, for instance, could have avoided a considerable amount of
embarrassment recently if it had not attempted to shift the blame for faulty
acceleration mechanisms to other manufacturers and drivers, and had instead
admitted that it had been using an inappropriate design.
If these future lines of enquiry refine the MEP scale and continue to confirm its
validity, then it will be a very useful tool for unlocking the black box of managerial
ethical decision making. With increased self-awareness and more insightful
management of the ethical strengths and weakness within organisations, the
disruptive consequences of unethical behaviour in corporate life are likely to be less
tragic than they have been in the recent past.
In conclusion, the findings of this research highlight an area of growing concern to
health care organisations, government, and society. Managerial ethics, especially in
health care, are of concern to both current and future administrators. The ethical
Ethical decision making and health care managers | 178
issues of health care administration are likely to attract increased attention because of
the growing concern regarding the ethical and economic dimensions of
administration and decision making. Further research in this area would shed new
light on these growing concerns.
Ethical decision making and health care managers | 179
References
Ampofo, A. A. (2005). An empirical investigation into the relationship of
organizational ethical culture to ethical decision-making by
accounting/finance professionals in the insurance industry in the
U.S.A. D.B.A. dissertation, Nova Southeastern University, United States -
Florida. Retrieved from ABI/INFORM Global. (Publication No. AAT
3158662).
Ang, S. H., & Wight, A.M. (2009). Building intangible resources: The stickiness of
reputation. Corporate Reputation Review, 12(1), 21–31.
Angelidis, J., & Ibrahim, N. (2004). An exploratory study of the impact of degree of
religiousness upon an individual's corporate social responsiveness orientation.
Journal of Business Ethics, 51(2), 119.
Armstrong, R. W., (1996). The relationship between culture and perception of ethical
problems in international marketing. Journal of Business Ethics, 15(11),
1199.
Ashkanasy, N. M., Windsor, C. A., & Trevino, L. K. (2006). Bad apples in bad
barrels revisited: cognitive moral development, just world beliefs, rewards,
and ethical decision-making. Business Ethics Quarterly, 16(4), 449.
Au, A. K. M., & Wong, D. S. N. (2000). The impact of Guanxi on the ethical
decision-making process of auditors: An exploratory study on Chinese CPAs
in Hong Kong. Journal of Business Ethics, 28(1), 87.
Australian Institute of Health and Welfare. (2010). Australian Hospital Statistics
2008-09, retrieved from
http://www.aihw.gov.au/publications/hse/84/11173.pdf
Axline, L. L. (1990). The bottom line on ethics. Journal of Accountancy, 170(6), 87.
Balthazard, P. A., Cooke, R. A., & Potter, R. E. (2006). Dysfunctional culture,
dysfunctional organization: Capturing the behavioral norms that form
Ethical decision making and health care managers | 180
organizational culture and drive performance. Journal of Managerial
Psychology, 21(8), 709–732.
Bampton, R., & Maclagan, P. (2009). Does a 'care orientation' explain gender
differences in ethical decision making? A critical analysis and fresh findings.
Journal of Business Ethics, 18(2), 179.
Barnett, J. E., Behnke, S. H., Rosenthal, S. L., & Koocher, G. P. (2007). In case of
ethical dilemma, break glass: commentary on ethical decision making in
practice. Professional Psychology: Research & Practice, 38(1), 7-12.
Barnett, J. H., & Karson, M. J. (1989). Managers, values, and executive decisions:
An exploration of the role of gender, career stage, organisational level,
function, and the importance of ethics, relationships and results in managerial
decision-making. Journal of Business Ethics, 8(10), 747–771.
Barnett, T. (1992). A preliminary investigation of the relationship between selected
organisational characteristics and external whistleblowing by employees.
Journal of Business Ethics, 11(12), 949–959.
Barnett, T., Bass, K., & Brown, G. (1996). Religiosity, ethical ideology, and the
intentions to report a peer’s wrongdoing. Journal of Business Ethics, 15(11),
1161–1174.
Barnett, T., Bass, K., Brown, G., & Hebert, F. J (1998). Ethical ideology and the
ethical judgments of marketing professionals. Journal of Business Ethics,
17(7), 715–723.
Barnett, T., Cochran, D. S., & Taylor, S. G., (1993). The internal disclosure policies
of private-sector employers: An initial look at their relationship to employee
whistleblowing. Journal of Business Ethics, 12(2), 127.
Bartels, L. K., Harrick, E., Martell, K., & Strickland, D. (1998). The relationship
between ethical climate and ethical problems within human resource
management. Journal of Business Ethics, 17(7), 799.
Bateman, C. R., Fraedrich J. P., & Iyer, R. (2003). The integration and testing of the
Janus-Headed Model within marketing. Journal of Business Research, 56(8),
587–596.
Ethical decision making and health care managers | 181
Baumhart, R. (1961). Problems in review: How ethical are businessmen? Harvard
Business Review, 39(4), 6–9.
Baumhart, R., (1969). Teaching and researching business ethics. Review of Social
Economy, 27(1), 65–73.
Bazerman, M. H. (2005). Judgment in managerial decision making. (2nd ed.). New
York: Wiley.
Becker, H., & Fritzsche, D. (1987). Business ethics: A cross-cultural comparison of
managers’ attitudes. Journal of Business Ethics, 6(4), 289–295.
Beekun, R., Hamdy, R., Westerman, J., & Hassabelnaby, H. (2008). An exploration
of ethical decision-making processes in the united states and egypt. Journal
of Business Ethics, 82(3), 587.
Bernardi, R., & Guptill, S. (2008). Social desirability response bias, gender, and
factors influencing organisational commitment: An international study.
Journal of Business Ethics, 81(4), 797.
Bhuyan, N. (2007). The role of character in ethical decision making. The Journal of
Value Inquiry, 41(1), 45–57.
Boatright, J. R. (Ed.). (2007). Ethics and the conduct of business (5th ed.). Upper
Saddle River, New Jersey: Prentice Hall.
Bohr, R. H., & Kaplan, H. M. (1971). Employee protest and social change in the
health care organisation. American Journal of Public Health, (61)11, 2229–
2235.
Boone, L., & Macdonald, C. (2009). Broadcasting operation iraqi freedom: The
people behind cable news ethics, decisions, and gender differences. Journal
of Business Ethics, 84, 115.
Bowen, S. (2004). Organisational factors encouraging ethical decision making: An
exploration into the case of an exemplar. Journal of Business Ethics, 52(4),
311.
Braithwaite, J., Travaglia, J., & Ledema, R. (2006). Patient Safety: A comparative
analysis of eight inquiries in six countries. University of NSW, Sydney:
Centre for Clinical Governance Research.
Ethical decision making and health care managers | 182
Briggs-Myers, I., McCaulley, M. H., Quenk, N. L., & Hammer, A. L. (1998). MBTI
Manual: A guide to the development and use of the Myers-Briggs type
indicator®. (3rd ed.). Palo Alto, California: Consulting Psychologists Press.
Browning, J., & Zabriskie, N. B. (1983). How ethical are industrial buyers?
Industrial Marketing Management, 12(4), 219–224.
Burnes, B. (2004). Managing Change: A strategic approach to organisational
dynamics. (4th ed.). Harlow, England: Financial Times Prentice Hall.
Callen-Marchione, K. S., & Ownbey, S. F. (2008). Associations of unethical
consumer behavior and social attitudes. Journal of Fashion Marketing and
Management, 12(3), 365.
Campbell, C. R. (2004). A longitudinal study of one organisation’s culture: Do
values endure? Mid-Americal Journal of Business, 19(2), 41.
Carroll, A. B. (1991). The Pyramid of Corporate Social Responsibility: Toward the
Moral Management of Organizational Stakeholders, Business Horizons,
34(4), 39–48.
Casali, G. L. (2007). A quest for ethical decision making: Searching for the holy
grail, and finding the sacred trinity in ethical decision making by managers.
Social Responsibility Journal, 3(3), 50-59.
Casali, G. L. (2008a). An evidence-based taxonomy of factors influencing ethical
decision making: A critical response to the current literature. Proceedings of
the Eben Research Conference, Lille, France.
Casali, G. L. (2008b). Creating managerial ethical profiles: An exploratory cluster
analysis. Electronic Journal of Business Ethics, 13(2), 27–34.
Casali, G. L. (2009). Developing a multidimensional scale for ethical decision
making: The Managerial Ethical Profile (MEP). Paper presented at the 23rd
Annual Australia and New Zealand Academy of Management Conference
(ANZAM 2009), Southbank, Melbourne.
Casali, G. L. & Day, G. (2010). Treating an unhealthy organisational culture: the
implications for managerial ethical decision making of the Bundaberg
Hospital Inquiry. Australian Health Review, 34(1), 73.
Ethical decision making and health care managers | 183
Chavez, G. A., Wiggins R. A., & Yolas, M. (2001). The impact of membership in the
Ethics Officer Association. Journal of Business Ethics, 34(1), 39.
Cohen, J. R., Pant, L., & Sharp, D. (2001). An examination of differences in ethical
decision-making between Canadian business students and accounting
professionals. Journal of Business Ethics, 30(4), 319.
Cohen, J. R., Pant, L., & Sharp, D. (2005). A validation and extension of a
Multidimensional Ethics Scale. Journal of Business Ethics, 12(1), 13–26.
Collins, C. J. (2007). The interactive effects of recruitment practices and product
awareness on job seekers' employer knowledge and application behaviors.
Journal of Applied Psychology, 92(1), 180–190.
Collins-Chobanian, S. (Ed.). (2004). Ethical challenges to business as usual. Upper
Saddle River, New Jersey: Prentice Hall.
Comunian, A. L., & Gielen, U. P. (2006). Promotion of moral judgement maturity
through stimulation of social relo-taking and social reflection: an Italian
intervention study. Journal of Moral Education, 35(1), 51–69.
Coomer, K. (2007). Corporate cultures. Occupational Health, 59(4), 28.
Coughlan, R. (2005). Codes, values and justifications in the ethical decision-making
process. Journal of Business Ethics, 59(1-2), 45.
Crisp, R. (Ed.). (2000). Aristotle: Nicomachean ethics (R. Crisp, Trans.) Cambridge,
England: Cambridge University Press. (Original work published c.340 BCE).
Curtis, M. B. (2006). Are audit-related ethical decisions dependent upon mood?
Journal of Business Ethics, 68(2), 191.
Dadisho, Edmond W. (2005). Ethical decision making in law enforcement: A
comparison of education level, moral development, and personal
conduct. M.S. dissertation, California State University, Long Beach, United
States - California. Retrieved from Dissertations & Theses: Full Text.
(Publication No. AAT 1429274).
Davies, H. G. (2005). Queensland Public Hospitals Commission of Inquiry (The
Davies Report). Retrieved from http://www.qphci.qld.gov.au/
Ethical decision making and health care managers | 184
Davis, M. A., Andersen, M. G. & Curtis, M. B. (2001). Measuring ethical ideology
in business ethics: A critical analysis of the Ethics Position Questionnaire.
Journal of Business Ethics, 32(1), 35–45.
Davis, M. A., Johnson, N. B., & Ohmer D. G. (1998). Issue-contingent effects on
ethical decision making: A cross-cultural comparison. Journal of Business
Ethics, 17(4), 373–389.
De Vaus, D.A. (2002). Surveys in social research. London: Routledge.
DeConinck, J. B., & Lewis, W. F. (1997). The influence of deontological and
teleological considerations and ethical climate on sales managers’ intentions
to reward or punish sales force behaviour. Journal of Business Ethics 16(5),
497.
Deshpande, S. (2009). A study of ethical decision making by physicians and nurses
in hospitals. Journal of Business Ethics, 90(3), 387.
DeVellis, R. (2003). Scale Development Theory and Application. (2nd ed.). Thousand
Oaks, California: Sage Publications
Dictionary.com (2010). Profiling. Retrieved from
http://dictionary.reference.com/browse/profiling.
Dion, M. (1996). Organisational culture as matrix of corporate ethics. The
International Journal of Organisational Analysis, 4(4), 329–351.
Donald, H. S. (2006). Three proposed perspectives of attitude toward business'
ethical responsibilities and their implications for cultural comparison.
Business and Society Review, 111(1), 15.
Dopfer, K., Foster, J., & Potts, J. (2004). Micro-meso-macro, Journal of
Evolutionary Economics, 14(1), 263–279.
Doty, E., Tomkiewicz, J., & Bass, K. (2005). Sex differences in motivational traits
and ethical decision making among graduating accounting majors. College
Student Journal, 39(4), 817.
Edwards, J. R., & Parry, M. E. (1993). On the Use of Polynomial Regression
Equations as an Alternative to Difference Scores in Organisational Research.
Academy of Management Journal, 36(6), 1577–1613.
Ethical decision making and health care managers | 185
Enderle, G. (1997). In search of a common ethical ground: corporate environmental
responsibility from the perspective of Christian environmental stewardship.
Journal of Business Ethics, 16 (2), 173–182.
Erez, M. & Gati, E. (2004). A dynamic, multilevel model of culture: From micro
level of the individual to the macro level of a global culture. Applied
Psychology: An International Review, 52(4), 483–598.
Ethics Resource Centre. (2005, December 31). The 2005 National Business Ethics
Survey. Retrieved from http://www.ethics.org/resource/2005-national-
business-ethics-survey.
Etter, S., Cramer, J. J., & Finn, S. (2007). Origins of academic dishonesty: Ethical
orientations and personality factors associated with attitudes about cheating
with information technology. Journal of Research on Technology in
Education, 39(2), 133–156.
Everitt, B. S. (1993). Cluster analysis (3rd ed.). London: Edward Arnold.
Fan, W., Gordon, M., Pathak, P. (2006). On linear mixture of expert approaches to
information retrieval. Decision Support Systems, 42(2), 975–987.
Farrell, L. U. (2002, March 15). Workplace bullying’s high cost: $180M in lost time,
productivity. Orlando Business Journal. Retrieved from
http://orlando.bizjournals.com/orlando/stories/2002/03/18/focus1.html
Ferrell, O. C., Fraedrich, J., & Ferrell, L. (2005). Business ethics: Ethical decision
making and cases (6th ed.). Boston: Houghton Mifflin.
Ferrell, O. C., Fraedrich, J., & Ferrell, L. (2008). Business ethics: Ethical decision
making and cases (7th ed.). Boston: Houghton Mifflin.
Ferrell, O. C, Gresham, L. G., & Fraedrich, J. (1989). A Synthesis of Ethical
Decision Model for Marketing. Journal of Macromarketing, 9(2), 55–64.
Finigan, J. & Theriault C. (2006). The relationship between personal values and the
perception of the corporation’s code of ethics, Journal of Applied Social
Philosophy, 27(8), 708–724.
Fisher, C. & Lovell, A., (2003). Business ethics and values. Harlow, England:
Financial Times Prentice Hall.
Ethical decision making and health care managers | 186
Ford, R. C., & Richardson, W. D. (1994). Ethical decision making: A review of the
empirical literature. Journal of Business Ethics, 13(3), 205.
Forsyth, D. R., (1980). A taxonomy of ethical ideologies, Journal of Personality and
Social Psychology 39(1), 175–184.
Forsyth, D. R. (1981). Moral judgment: The influence of ethical ideology.
Personality and Social Psychology Bulletin, 7(2), 218–223.
Forsyth, D. R. (1985). Individual differences in information integration during moral
judgment. Journal of Personality and Social Psychology, 49(1), 264–272.
Forsyth, D. R. (1992). Judging the morality of business practices: The influence of
personal moral philosophies. Journal of Business Ethics, 11(5–6), 461–470.
Forsyth, D. R., Nye, J. L., & Kelley, K. (1988). Idealism, relativism and the ethic of
caring. The Journal of Psychology, 122(3), 243-248.
Foster, B., Mackie, B., & Barnett, N. (2004). Bullying in the health sector: A study
of bullying of nursing students. New Zealand Journal of Employment
Relations, 29(2), 67–83.
Foster. P. (2005). Queensland Health System Review Final Report. Brisbane:
Queensland Health. Retrieved from
http://www.health.qld.gov.au/health_sys_review/final/qhsr_final_report.pdf
Frame, M. W., & Williams, C. B. (2005). A model of ethical decision making from a
multicultural perspective. Counseling and Values, 49(3), 165.
Frankena, W. K. (1973). Ethics (2nd ed.). In Foundation of Philosophy Series. NJ:
Prentice Hall.
French, E. L. & Casali, G. L. (2008). Ethics in emergency medical services – who
cares? An exploratory analysis from Australia. Electronic Journal of Business
Ethics and Organisation Studies, 13(2), 44–53.
Friedman, M. (1970, September 13). A Friedman doctrine—The social responsibility
of business is to increase its profits. New York Times, p. 1.
Fritzsche, D., & Oz, E. (2007). Personal Values' Influence on the Ethical Dimension
of Decision Making. Journal of Business Ethics, 75(4), 335.
Ethical decision making and health care managers | 187
Galloro, V. (2000). Ethics and the practice manager. Modern Healthcare, 30(40),
54–55.
Gilligan, C. (1982). In a different voice: Women’s conceptions of the self and
morality. Harvard Educational Review, 47(4), 481–517.
Glover, S. H., Bumpus, M. A., Logan, J. E., & Ciesla, J. R. (1997). Re-examining the
Influence of Individual Values on Ethical Decision Making. Journal of
Business Ethics, 16(12-13).
Gordon, A. D. (1999). Classification (2nd ed.). London: Chapman & Hall/CRC.
Grace, D., & Cohen, S. (Eds.). (1995). Business ethics: Australian problems and
cases. Melbourne: Oxford University press.
Gross, M. (1997). Ethics and activism: the theory and practice of political morality.
New York: Cambridge University Press.
Gunz, S., & Gunz, H. (2008). Ethical decision making and the employed lawyer.
Journal of Business Ethics, 81(4), 927.
Gupta, S. (2010). A multidimensional ethics scale for Indian managers’ moral
decision making. Electronic Journal of Business Ethics and Organisation
Studies, 15(1), 5–14.
Guy, M. E. (Ed.). (1990). Ethical decision making in everyday work situations. New
York: Quorom Books.
Hagan J., & Moon C. (2001). New economy, new ethics. In C. Moon & C. Bonney,
Business ethics: Facing up the issue (pp. 7–21). London: Profile Books.
Hair, J. F., Jr., Babin, B., Money, A. H., & Samouel, P. (2003). Essentials of
Business Research Methods. New York: John Wiley & Sons.
Hair, J. F., Black, B., Babin, B., Anderson, R. E., & Tatham, R. L., & (2003).
Multivariate data analysis: Global edition with readings (6th ed.). Upper
Saddle River, New Jersey: Prentice Hall.
Halwani, R. (2003). Care ethics and virtue ethics. Hypatia, 18(3), 161.
Hartman, S., Fok, L., & Zee, S. (2009). An examination of ethical values among
black and white subjects and among males and females. Journal of Legal,
Ethical, and Regulatory Issues, 12(2), 1.
Ethical decision making and health care managers | 188
Hegarty, W. H., & Sims H. P. Jr., (1979). Organisational philosophy, policies, and
objectives related to unethical decision behavior: A laboratory experiment.
Journal of Applied Psychology, 64(3), 331.
Hinman, L. (2007). Ethics: A pluralistic approach to moral theory. (4th ed.). US:
Wadsworth Publishing.
Hinman, L. (Ed.). (2003). Ethics: A pluralistic approach to moral theory (3rd ed.).
Belmont, California: Thomson Wadsworth.
Hollingsworth, J. A., Hall, E. H., Jr., & Trinkaus, R. J. (1991). Utilitarianism: An
ethical framework for compensation decision making. Review of Business,
13(3), 17.
Hosmer, L. T. (Ed.). (2006). The ethics of management (5th ed.). Boston,
Massachusetts: McGraw Hill.
Hou, J., & Elliott, K. (2010). Profiling Online Bidders. Journal of Marketing Theory
and Practice, 18 (2), 109–126.
Hunt, S. D., Kiecker, P. L., & Chomko, L. B. (1990). Social responsibility and
personal success: A research note. Academy of Marketing Science Journal,
18(3), 239.
Ingram, T., N, LaForge, R. W., & Schwepker, J., Charles H. (2007). Salesperson
ethical decision making: the impact of sales leadership and sales management
control strategy. The Journal of Personal Selling & Sales Management,
27(4), 301.
Ishida, C. (2006). How do scores of DIT and MJT differ? A critical assessment of the
use of alternative moral development scales in studies of business ethics.
Journal of Business Ethics, 67(1), 63–74.
Jackson, T. (2000). Management ethics and corporate policy: A cross-cultural
comparison. Journal of Management Studies, 37(3), 349–369.
Jamieson, D. (1991). Method and moral theory. In P. Singer (Ed.), A companion to
ethics (pp. 476–489). Oxford: Blackwell.
Jewe, R. (2008). Do Business Ethics Courses Work? The Effectiveness of Business
Ethics Education: An Empirical Study. Journal of Global Business Issues, 1.
Ethical decision making and health care managers | 189
Jirasek, J. A. (2003). Two approaches to business ethics. Journal of Business Ethics,
47(4), 343.
Johnson, C. E. (2007). Ethics in the workplace: Tools and tactics for organisational
transformation. Thousand Oaks, California: SAGE Publications.
Jones, T. M. & Gautschi, F. H. (1988). Will the ethics of business change? A survey
of future executives. Journal of Business Ethics, 7(4), 231.
Joreskog, K., (1969). A general approach to confirmatory maximum likelihood factor
analysis. Phychometrica, 34(2), 183–202.
Jung, I. (2009). Ethical judgments and behaviours: Applying a Multidimensional
Ethics Scale to measuring ICT ethics of college students. Computers &
Education, 53(3), 940–949.
Kabanoff, B., Waldersee, R., & Cohen, M. (1995). Espoused values and
organisational change themes. Academy of Management Journal, 38(4),
1075-1104.
Kark, R., & Van Dijk, D. (2007). Motivation to lead, motivation to follow: The role
of the self-regulatory focus in leadership processes. Academy of Management
Review, 32(2), 500–529.
Kavathatzopoulos, I. (2003). The use of information and communication technology
in the training for ethical competence in business. Journal of Business Ethics,
48(1), 43.
Keller, A. C., Smith, K. T., & Smith, L. M. (2007). Do gender, educational level,
religiosity, and work experience affect the ethical decision making of US
accountants? Critical Perspectives on Accounting, 18(3), 299-314.
Kelley, S. W., Ferrell, O. C., & Skinner, S. J. (1990). Ethical behavior among
marketing researchers: An assessment. Journal of Business Ethics, 9(8), 681.
Kidwell, J. M., Stevens, R. E. & Bethke, A. L. (1987). Differences in Ethical
Perceptions Between Male and Female Managers: Myth or Reality? Journal
of Business Ethics, 6(6), 489.
King, S. M. (2007). Religion, spirituality, and the workplace: Challenges for public
administration. Public Administration Review, 67(1), 103.
Ethical decision making and health care managers | 190
Kline, R. B. (2005). Principles and practice of structural equation modelling (2nd
ed). New York: Guilford Press.
Knapp, S., & Vandecreek, L. (2007). When values of different cultures conflict:
Ethical decision making in a multicultural context. Professional Psychology:
Research & Practice, 38(6), 660–666.
Kohlberg, L. (1969). Stage and Sequence: The cognitive developmental approach to
socialization. In D. A. Golsin (Ed.), Handbook of socialization theory and
research (pp. 347-480). New York: Rand McNally.
Kohlberg, L. (1979). The meaning and measurement of moral development.
Worchester, MA: Clark University Press.
Kohut, A. (2004, May 23). How journalists see journalists in 2004. Pew Research
Center for the People & The Press. Retrieved from http://people-
press.org/report/214/bottom-line-pressures-now-hurting-coverage-say-
journalists
Krebs, D. L., & Denton, K. 2005. Toward a more pragmatic approach to morality: A
critical evaluation of Kohlberg’s model. Psychological Review, 112(3), 629–
649.
Kretschmer, E. (1925). Physique and Character: an investigation of the nature of
constitution and of the theory of temperament. trans. W. J. H. Sprott. New
York: Harcourt Brace.
Kujala, J., & Pietiläinen, T. (2004). Female managers' ethical decision making: A
multidimensional approach. Journal of Business Ethics, 53(1-2), 153.
Kurpis, L., Beqiri, M., & Helgeson, J. (2008). The effects of commitment to moral
self-improvement and religiosity on ethics of business students. Journal of
Business Ethics, 80(3), 447.
Laabs, J. (1999). Personality fit: A new approach to recruiting. Workforce Journal,
78(8), 89–95.
Lavater, J.K. (1775). Essays on Physiognomy. Zurich: Switzerland
Liedtka, J. M. (1989). Value congruence: The interplay of individual and
organisational value systems. Journal of Business Ethics, 8(10), 805–815.
Ethical decision making and health care managers | 191
Liedtka, J. M. (1992). Exploring ethical issues using personal interviews. Business
Ethics Quarterly, 2(2), 161-181.
Lin, C-Y., & Ho, Y-H. (2008). An examination of cultural differences in ethical
decision making using the multidimensional ethics scale. Social behaviour
and Personality 36(9), 1213–1222.
Lind, G. (1978). How does One Measure Moral Judgment? Problems and Alternative
Ways of Measuring a Complex Construct (pp. 171–201). In G. Portele (ed.),
Sozialisation und Moral Basel: Beltz.
Lind, G., (1995). The meaning and measurement of moral judgment revisited. Paper
presented at the American Educational Research Association, San Francisco.
Loe, T. W., Ferrell, L., & Mansfield, P. (2000). A review of empirical studies
assessing ethical decision making in business. Journal of Business Ethics,
25(3), 185.
Lund, D. (2008). Gender differences in ethics judgment of marketing professionals in
the united states. Journal of Business Ethics, 77(4), 501.
Maak, T., & Pless, N.M. 2006, Responsible leadership in a stakeholder society: A
relational perspective. Journal of Business Ethics, 66(1), 99–115.
Mackie, J. E. (2004). Ethical decision making in bioscience companies: Case studies
and a comparative analysis. M.Sc. dissertation, University of Toronto
(Canada), Canada. Retrieved from ABI/INFORM Global. (Publication No.
AAT MR02436).
Madas, E., & North, N. (2000). Management challenges faced by managers of New
Zealand long-term care facilities. Australian Health Review, 23(1), 100–113.
Mäenpää, K. (2006). Clustering the consumers on the basis of their perceptions of
the internet banking services. Internet Research, 16(3), 304.
Marc, S., & Vera, L. S. (2006). The effects of escalating commitment on ethical
decision-making. Journal of Business Ethics, 64(4), 343.
Marshall, B., & Dewe, P. (1997). An investigation of the components of moral
intensity. Journal of Business Ethics, 16(5), 521–530.
Ethical decision making and health care managers | 192
Marshall, J. (2005). An introduction to Mill's utilitarian ethics. The Review of
Metaphysics, 58(3), 691.
Marta, J., Singhapakdi, A., & Kraft, K. (2008). Personal Characteristics Underlying
Ethical Decisions in Marketing Situations: A Survey of Small Business
Managers. Journal of Small Business Management, 46(4), 589.
Mason, C., & Wilson-Evered., E. (1999). Developing core values for a health care
facility. Queensland: Royal Brisbane Hospital Health Care Symposium.
Mathieson, K. (2007). Towards a Design Science of Ethical Decision Support.
Journal of Business Ethics, 76(3), 269.
McCabe, A. C., Rhea, I., & Mary Conway, D.O. (2006). The business of ethics and
gender. Journal of Business Ethics, 64(2), 101.
McCabe, D. L., Trevino L. K., & Butterfield. K. D. (1996). The influence of
collegiate and corporate codes of conduct on ethics-related behavior in the
workplace. Business Ethics Quarterly, 6(4), 461–476.
McCabe, R., & Conway, M. D. (2006). The business of ethics and gender. Journal of
Business Ethics, 64(2), 101.
McDevitt, R., Giapponi, C., & Tromley, C. (2007). A model of ethical decision
making: The integration of process and content. Journal of Business Ethics,
73(2), 219–229.
McDonald, P., & Gandz, J. (2006). Identification of values relevant to business
research. Human Resource Management, 30(2), 217-236.
McDonald, R. P. (1999). Test Theory: A unified treatment. Mahwah, NJ: L. Erlbaum
Associates.
McGowan, M. K., Stephens, P., & Gruber, D. (2007). An exploration of the
ideologies of software intellectual property: The impact on ethical decision
making. Journal of Business Ethics, 73(4), 409.
McKendall, M., DeMarr. B, & Jones-Rikkers, C. (2002). Ethical compliance
programs and corporate illegality: Testing the assumption of corporate
sentencing guidelines. Journal of Business Ethics, 37(4), 367.
Ethical decision making and health care managers | 193
McMahon, J. M., & Harvey, R. J. (2007). The effect of moral intensity on ethical
judgment. Journal of Business Ethics, 72(4), 335.
McMahon, L. (2000). Bullying and harassment in the workplace. International
Journal of Contemporary Hospitality Management, 12(6), 384-387
McMahon, S. (2007, Dec 20). Wheat board executives face $14m fines threat over
Iraq. Herald Sun. Retrieved from
http://www.heraldsun.com.au/news/national/awb-scandal-to-court/story-
e6frf7l6-1111115157116
McNamara, C. (1999). Organisational culture. Retrieved from
http://www.managementhelp.org/org_thry/culture/culture.htm
McNichols, C. W. and T.W. Zimmerer. (1985). Situational ethics: An empirical
study of differentiators of student attitudes. Journal of Business Ethics, 4(3),
175-180.
Micewski, E. R., & Troy, C. (2007). Business ethics - Deontologically revisited.
Journal of Business Ethics, 72(1), 17–25.
Minkes, A. L., Small, M. W., and Chatterjee, S.R. (1999). Leadership and business
ethics: Does it matter? Implications for management. Journal of Business
Ethics, 20(4), 327–335.
Morse, J. (1998). The missing link between virtue theory and business ethics.
Journal of Applied Philosophy, 16(1), 47–58.
Morton, A. P. (2005). Reflections on the Bundaberg Hospital failure. Medical
Journal of Australia, 183(6), 328-329.
Murphy, P. R., Smith, J. E. & Daley, J. M. (1992). Executive attitudes, organisational
size and ethical issues: Perspectives on a service industry. Journal of
Business Ethics, 11(1), 11.
Mustamil, N., & Quaddus, M. (2009). Cultural influence in the ethical decision
making process: The perspective of malaysian managers. The Business
Review, Cambridge, 13(1), 171.
Ethical decision making and health care managers | 194
Ng, J., White, G., Lee, A., & Moneta, A. (2009). Design and validation of a novel
new instrument for measuring the effect of moral intensity on accountants'
propensity to manage earnings. Journal of Business Ethics, 84(3), 367.
Nguyen, N., Basuray, M., Smith, W., Kopka, D., & McCulloh, D. (2008). Moral
issues and gender differences in ethical judgment using Reidenbach and
Robin's (1990) multidimensional ethics scale: Implications in teaching of
business ethics. Journal of Business Ethics, 77(4), 417.
Nill, A., & Schibrowsky, J., A. (2005). The impact of corporate culture, the reward
system, and perceived moral intensity on marketing students' ethical decision
making. Journal of Marketing Education, 27(1), 68.
Nunnally, J. C., & Bernstein, I. H. (1994). Psychometric theory (3rd ed.). New York:
McGraw-Hill.
O'Fallon, M. J., & Butterfield, K. D. (2005). A review of the empirical ethical
decision-making literature: 1996–2003. Journal of Business Ethics, 59(4),
375.
O'Leary, C., & Pangemanan, G. (2007). The effect of groupwork on ethical decision
making of accountancy students. Journal of Business Ethics, 75(3), 215.
Oumlil, A., & Balloun, J. (2009). Ethical decision making differences between
American and Moroccan managers. Journal of Business Ethics, 84(4), 457.
Palermo, J., & Evans, A. (2007). Relationships between personal values and reported
behavior on ethical scenarios for law students. Behavioral Sciences & the
Law, 25(1), 121.
Paradice, D. B., & Dejoie, R. M. (1991). The ethical decision-making processes of
information systems workers. Journal of Business Ethics, 10(1), 1–21.
Patel, T., & Schaefer, A. (2009). Making sense of the diversity of ethical decision
making in business: An illustration of the Indian context. Journal of Business
Ethics, 90(2), 171.
Peer, K., & Rakich, J. (1999). Ethical decision making in healthcare management.
Hospital Topics, 77(4), 7.
Ethical decision making and health care managers | 195
Peterson, D.K. (2002). The relationship between unethical behavior and the
dimensions of the ethical climate questionnaire. Journal of Business Ethics,
41(4), 313–326.
Pollock, J. M. (2004). Ethics in crime and justice: Dilemmas and decisions. (4th ed.).
Belmont, California: Wadsworth/Thomson Learning.
Posner, B. Z., & Schmidt, W. H. (1993). Values congruences and differences
between the interplay of personal and organisational value systems. Journal
of Business Ethics, 12(5), 341-347.
Prentice, R. (2007). Ethical decision making: More needed than good intentions.
Financial Analysts Journal, 63(6), 17.
Queensland Government. (2010). Public Sector Ethics Act 1994. Retrieved from
http://www.legislation.qld.gov.au/acts_sls/Acts_SL_P.htm.
Queensland Health. (2005). Issue Paper for Bundaberg Hospital Commission of
Inquiry. Paper 1: Health Workforce, Medical Workforce. Brisbane:
Queensland Health. Retrieved from
http://www.health.qld.gov.au/inquiry/submissions.asp
Queensland Health. (2006). Queensland Health Code of Conduct. Retrieved from
http://www.health.qld.gov.au/about_qhealth/cc.asp
Queensland Health. (2009). Company profile. Retrieved from
www.health.qld.gov.au/performance/staffing/staff13yr_09.pdf
Rallapalli, K. C., Vitell, S. J., & Barnes, J. H. (1998). The influence of norms on
ethical judgments and intensions: An empirical study of marketing
professionals. Journal of Business Research 43(3), 157–168.
Rayner, C. and Cooper, C. (1997). Workplace bullying: myth or reality-can we
afford to ignore it? Leadership and Organization Development Journal,
18(4), 211-214
Reidenbach, R. E., & Robin, D. P. (1988). Some initial steps toward improving the
measurement of ethical evaluations of marketing activities. Journal of
Business Ethics, 7(11), 871–879.
Ethical decision making and health care managers | 196
Reidenbach, R. E., & Robin, D. P. (1990). Toward the development of a
multidimensional scale for improving evaluations of business ethics. Journal
of Business Ethics, 9(8), 639–653.
Rest, J. (1979). Development in judging moral issue. Minneapolis: University of
Minnesota Press
Rest, J. (1990). DIT Manual (3rd ed.). Minneapolis: Center for the Study of Ethical
Development.
Robertson, D. C. & Schlegelmilch, B. B. (1993). Corporate institutionalization of
ethics in the United States and Great Britain. Journal of Business Ethics,
12(4), 301.
Robinson, D. A., Davidsson, P., van der Mescht, H., & Court, P. (2007). How
entrepreneurs deal with ethical challenges: An application of the business
ethics synergy star technique. Journal of Business Ethics, 71(4), 411–423.
Rogers, V., & Smith, A. (2001). Ethics, moral development, and accountants-in-
training. Teaching Business Ethics, 5(1), 1–6.
Rolland, P.D. (2009). Whistle blowing in healthcare: An organisational failure in
ethics and leadership. Internet Journal of Law, Healthcare and Ethics, l6(1),
52–63.
Rosen, P., Hall, D., & Stainer, L. (2005). Sustainability and ethical decision making:
the Bovince case. International Journal of Management & Decision Making,
6(3,4), 359.
Rottig, D., & Heischmidt, K. A. (2007). The importance of ethical training for the
improvement of ethical decision making: Evidence from Germany and the
United States. Journal of Teaching in International Business, 18(4), 5.
Roxas, M. L., & Stoneback, J. Y. (2004). The importance of gender across cultures
in ethical decision making. Journal of Business Ethics, 50(2), 149.
Sandall, R. (2005, December, 10). Doctor death in bundaberg. Retrieved from
http://www.rogersandall.com/doctor-death-in-bundaberg/
Sashkin, M., Rosenbach, W. E., & Sashkin, M. G. (1997). Development of the power
need and its expression in leadership and management with a focus on leader-
Ethical decision making and health care managers | 197
follower relations. In L. S. Estabrook (Ed.), Leadership as legacy:
Proceedings of the twelfth scientific meeting of the A. K. Rice Institute.
Jupiter, FL: A. K. Rice Institute.
Saunders, P., Huynh, A., & Goodman-Delahunty, J. (2007). Defining workplace
bullying behaviour professional lay definitions of workplace bullying.
International Journal of Law and Psychiatry, 30(4), 340–354.
Schermerhorn, J.R. Jr. (2005). Management. (8th ed.). New York, NY: Wiley.
Schnietz, K. E., & Epstein, M. J. (2005). Exploring the financial value of a reputation
for corporate social responsibility during a crisis. Corporate Reputation
Review, 7(4), 327-345.
Scott, W. G., & Hart, D. K. (1979). Organisational America. Boston, Massachusetts:
Houghton Mifflin.
Scott-Hunt, S., & Lim, H. (2005). To pay suspicious attention: Following the weave
of ‘mixed logics’ in women’s ethical decision making. Feminist Legal
Studies, 13(2), 205-237.
Sekerka, L. (2009). Organisational ethics education and training: a review of best
practices and their application. International Journal of Training &
Development, 13(2), 77.
Serwinek, P. J. (1992). Demographic and related differences in ethical views among
small businesses. Journal of Business Ethics, 11(7), 555.
Shafer, W. E., Morris, R. E., & Ketchand, A. A. (2001). Effects of personal values on
auditors’ ethical decisions. Accounting, Auditing & Accountability Journal,
14(3), 254–277.
Shawver, T. J., & Sennetti, J. T. 2009, measuring ethical sensitivity and evaluation.
Journal of Business Ethics, 88(4), 663–678.
Shultz, S. F. (2003). Developing strategic boards of directors. Strategic Finance,
85(5), 22-27.
Sims, R. R., & Brinkmann, J. (2003). Enron ethics (Or: culture matters more than
codes). Journal of Business Ethics, 45(3), 243–256.
Ethical decision making and health care managers | 198
Singh, J., Vitell, S., Al-Khatib, J., & Clark III, I. (2007). The role of moral intensity
and personal moral philosophies in the ethical decision making of marketers:
A cross-cultural comparison of China and the United States. Journal of
International Marketing, 15(2), 86.
Skitmore, R. M., Stradling, S. G., & Tuohy, A. P. (1989). Project management under
uncertainty. Construct Management and Economics 7(2), 103–113.
Smith, N. C., Simpson, S., & Huang, C-Y. (2007). Why managers fail to do the right
thing: An empirical study of unethical and illegal conduct. Business Ethics
Quarterly, 17(4), 633.
Somers, M. J. (2001). Ethical codes of conduct and organisational context: A study
of the relationship between codes of conduct, employees’ behaviour, and
organisational values, Journal of Business Ethics, 30(2), 185-195.
Sparks, J. R., & Hunt, S. D. (1998). Marketing researcher ethical sensitivity:
Conceptualization, measurement, and exploratory investigation. Journal of
Marketing, 62(2), 92.
Sproles, G. B., & Kendall, E. L. (2005). A methodology for profiling consumers’
decision-making styles. The Journal of Consumer Affairs, 20(2), 267–279.
Srnka, K. J. (2004). Culture's role in marketers' ethical decision making: an
integrated theoretical framework. Academy of Marketing Science Review,
2004, 1.
Stainer, L. (2004). Ethical dimensions of management decision making. Strategic
Change, 13(6), 333.
Stead, W. E., Worrell, D. L. & Stead, J. G. (1990). An integrative model for
understanding and managing ethical behavior in business organizations.
Journal of Business Ethics, 9(3) 233–242.
Stevens, B. (2008). Corporate ethical codes: effective instruments for influencing
behavior. Journal of Business Ethics, 78(4), 601.
Svensson, G., & Wood, G. (2007). Strategic approaches of corporate codes of ethics
in Australia: A framework for classification and empirical illustration.
Corporate Governance, 7(1), 93–101.
Ethical decision making and health care managers | 199
Taft, S. H., & White, J. (2007). Ethics education: Using inductive reasoning to
develop individual, group, organisational, and global perspective. Journal of
Management Education, 31(5), 614–646.
Tenbrunsel, A. E. (1998). Misrepresentation and expectations of misrepresentation in
an ethical dilemma: The role of incentives and temptation. Academy of
Management Journal 41(3), 330.
Trevino, L.K (1986). Ethical decision making in organizations: A person-situation
interactionist model. Academy of Management Review, 11, 601-617.
Trevino, L. K., & Nelson, K. (2004). Managing business ethics: Straight talk about
how to do it right (3rd ed.). USA: John Wiley & Sons.
Trevino, L. K., & Youngblood, S. A. (1990). Bad apples in bad barrels: A causal
analysis of ethical decision-making behavior. Journal of Applied Psychology,
75(4), 378–385.
Trump, D. (2004). How to get rich. New York: Random House.
Valentine, S. R., & Rittenburg, T. L. (2007). The ethical decision making of men and
women executives in international business situations. Journal of Business
Ethics, 71(2), 125.
Van der Walt, N., Ingley, C., Shergill, G. S., & Townsend, A. (2006). Board
configuration: Are diverse boards better boards? Corporate Governance,
6(2), 129–147.
Van Hooft, V. (Ed.). (2005). Understanding virtue ethics. Durham, England:
Acumen Publishing.
Varsel, T., Adams, S.G., Pridie, S.J., & Ulloa, B.R. (2004). Team effectiveness and
individual Myers-Briggs personality dimensions. Journal of management in
engineering, 20(4), 141–146.
Veatch R. M., (1998). The place of care in ethical theory. Journal of Medicine and
Philosophy, 23(2), 210–224.
Victor, B., & Cullen, J. B. (1988). The organisational bases of ethical work climate.
Administrative Science Quarterly, 33(1), 101–125.
Ethical decision making and health care managers | 200
Victor, M. (2007). A practical approach to ethical decision making. Leadership in
Health Services, 20(2), 71.
Vitell, S., Bing, M., Davison, H., Ammeter, A., Garner, B., & Novicevic, M. (2009).
Religiosity and moral identity: The mediating role of self-control. Journal of
Business Ethics, 88(4), 601.
Vitell, S., & Patwardhan, A. (2008). The role of moral intensity and moral
philosophy in ethical decision making: a cross-cultural comparison of China
and the European Union. Business Ethics, 17(2), 196.
Walker, M. U. (Ed.). (1998). Moral understanding: A feminist study in ethics. New
York: Routledge.
Watson, G., & Berkley, R. (2009). Testing the value-pragmatics hypothesis in
unethical compliance. Journal of Business Ethics, 87(4), 463.
Weeks, W. A., Moore, C. W., McKinney, J. A., & Longenecker J. G. (1999). The
effects of gender and career stage on ethical judgment. Journal of Business
Ethics, 20(4), 301-313.
West, A. (2008). Sartrean Existentialism and Ethical Decision-Making in Business.
Journal of Business Ethics, 81(1), 15.
Whitcomb, L. L., Erdener, C. B., & Li, C. (1998). Business ethical values in China
and the US. Journal of Business Ethics, 17(8), 839–852.
Wilborn, L., Brymer, R., & Schmidgall, R. (2007). Ethical decisions and gender
differences of European hospitality students. Tourism and Hospitality
Research, 7(3-4), 230.
Wingfielt J., Bissell P., & Anserson C., 2003, The scope of pharmacy ethics: An
evaluation of the international research, 1990–2002. Social Science &
Medicine, 58(12), 2382.
Wood G., (2000). A cross-cultural comparison of the contents of codes of ethics:
USA, Canada, and Australia. Journal of Business Ethics, 25(4), 287–298.
Woodward, B., Davis, D. C., & Hodis, F. A. (2007). The relationship between ethical
decision making and ethical reasoning in information technology students.
Journal of Information Systems Education, 18(2), 193–203.
Ethical decision making and health care managers | 201
Workplace Bullying. (n.d). In Bully OnLine. Retrieved from
http://www.bullyonline.org/workbully/costs.htm
Young, S. B. (2007). Fiduciary duties as a helpful guide to ethical decision making in
business. Journal of Business Ethics, 74(1), 1.
Zentner, R. & Gelb, B. D. (1991). Scenarios: A Planning Tool for Health Care
Organisations. Hospital & Health Services Administration, 36(2), 211–212.
Zgheib, P. W. (2005). Managerial ethics: An empirical study of business students in
the American University of Beirut. Journal of Business Ethics, 61(1), 69–78.
Ethical decision making and health care managers | 202
Appendices
Appendix 1 MEP Questionnaire
When fulfilling the requirements of your position in your organisation, please indicate the importance of the followings in your decision-making process
1 providing the highest economic return (profit) for the organisation
Extremely important
Very important
Fairly important
Not very important
Not important at all
2 minimising costs for the organisation
Extremely important
Very important
Fairly important
Not very important
Not important at all
3 protecting the reputation of the organisation
Extremely important
Very important
Fairly important
Not very important
Not important at all
4 optimising resources of the district/hospital/unit/dept
Extremely important
Very important
Fairly important
Not very important
Not important at all
5 attaining organisational yearly budgets (short term)
Extremely important
Very important
Fairly important
Not very important
Not important at all
6 being in line with the organisational mission
Extremely important
Very important
Fairly important
Not very important
Not important at all
7 generating the greatest overall benefits for the district/hospital
Extremely important
Very important
Fairly important
Not very important
Not important at all
8 not harming the clients/patients
Extremely important
Very important
Fairly important
Not very important
Not important at all
9 respecting organisational’ rules and regulations that have been created for the greatest benefit for all stakeholders
Extremely important
Very important
Fairly important
Not very important
Not important at all
10
obeying the law (state and federal)
Extremely important
Very important
Fairly important
Not very important
Not important at all
11
creating the greatest overall benefit for the local community
Extremely important
Very important
Fairly important
Not very important
Not important at all
Ethical decision making and health care managers | 203
12
creating the greatest overall benefit for the wider community
Extremely important
Very important
Fairly important
Not very important
Not important at all
13
being most in line with your core personal values
Extremely important
Very important
Fairly important
Not very important
Not important at all
14
being most in line with the person you want to be
Extremely important
Very important
Fairly important
Not very important
Not important at all
15
respecting dignity of those affected by the decision
Extremely important
Very important
Fairly important
Not very important
Not important at all
16
being able to empathise with clients
Extremely important
Very important
Fairly important
Not very important
Not important at all
17
acting openly when making decision
Extremely important
Very important
Fairly important
Not very important
Not important at all
18
making “care for the sick” paramount in determining decision alternatives
Extremely important
Very important
Fairly important
Not very important
Not important at all
19
giving the opportunity to all affected parties or their representatives to have input into the decision making process
Extremely important
Very important
Fairly important
Not very important
Not important at all
20
treating others as you want others to treat you
Extremely important
Very important
Fairly important
Not very important
Not important at all
21
treat people as ends not as means Extremely important
Very important
Fairly important
Not very important
Not important at all
22
ensuring that confidentiality is maintained at all times
Extremely important
Very important
Fairly important
Not very important
Not important at all
23
maintaining a fair process at all times
Extremely important
Very important
Fairly important
Not very important
Not important at all
24
ensuring that the organisation “duty of care” is maintained at all times
Extremely important
Very important
Fairly important
Not very important
Not important at all
Please rate the following factors in terms of their influence on your decision making process
Individual factors
Ethical decision making and health care managers | 204
1 receiving rewards or minimising punishment to yourself (Kohlberg pre conventional)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
2 fulfilling expectation of your colleagues and boss (Kohlberg conventional)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
3 following your personal moral values regardless of other people’s opinions (Kohlberg post conventional
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
4 making a decision independently, and using the information available to you at the time (Vroom DM AI)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
5 making the decision independently but getting more information from collaborators (Vroom DM AII)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
6 making a decision independently but asking for tokenistic consultation from subordinates (Vroom DM CI)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
7 making a decision independently and only informing subordinates (Vroom DM CII)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
8 making a decision collaboratively through facilitation and engagement of subordinates (Vroom DM GI)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
9 relying heavily on your personal values in making decisions (Personal values)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
10
being guided by your professional experience (professional experience)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
11
being guided by experts in their fields (professional experience)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
Organisational factors
12
being in line with the hospital/district code of ethics/conduct (code of ethics)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
13
following ethical principles learnt during training provided by the organisation or from formal studies (ethical training)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
14
following ethical principles that you have learnt during your formal studies (ethical training)
Extremely Influenti
Very Influential
Influential
Not Too Influential
Not Influential At
Ethical decision making and health care managers | 205
al All
15
following ethical principles that you have learnt in a previous organisation (ethical training)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
16
being in line with the organisational culture (organisational culture)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
17
reaching a decision based by using evidence-based process (decision making process)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
18
reaching a decision by bargaining with superiors and subordinates (decision making process)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
19
reaching a decision by inspiring others (decision making process)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
20
reaching a decision by using personal judgment (decision making process)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
21
being in line with the mission statement of the company (mission statement)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
22
respecting your professional code of conduct (professional code of conduct)
Extremely Influential
Very Influential
Influential
Not Too Influential
Not Influential At All
Ethical decision making and health care managers | 206
External factors
23
political agendas compared to medical needs (Political)
extremely influential
very influential
influential
Not too influential
Not influential at all
24
fulfilling macro economic factors (Government budgets) (Economic)
extremely influential
very influential
influential
Not too influential
Not influential at all
25
covering existing health gaps in the community needs (social)
extremely influential
very influential
influential
Not too influential
Not influential at all
26
encouraging the technological advancement in terms of hardware and software where given high preference (technological)
extremely influential
very influential
influential
Not too influential
Not influential at all
27
promoting environment protection such as reduction of chemical waste and energy savings (environmental)
extremely influential
very influential
influential
Not too influential
Not influential at all
28
identify particular gaps between the community health needs, and the current level of satisfaction of those needs by competitors (competition)
extremely influential
very influential
influential
Not too influential
Not influential at all