Loyola University Chicago

Charles Webster
Assistant Professor
Department of Health Management Systems
Duquesne University
 

Presented at
The First Annual Ethics and Technology Conference
March 9, 1996
Loyola University of Chicago
Chicago, Illinois.
 

Abstract

Computer-related jobs have tripled in a decade. Whole new classes of users are being asked to design their own information systems, especially in health care where future information systems must support complex clinical and administrative tasks understood best by health care workers rather than by technologists. In this context, teaching the use of new tools for crafting information systems must contain a component of ideology because of the an implicit, technology-based, class struggle between the designer aristocrats and the user proletariat. As the bottle neck to successful application development ceases to involve domain task-unspecific arcane computer and information science knowledge, and increasingly involves knowledge of stereotypical health care domain objects, functions, and events, the technologist will inevitably recede into the roles of infrastructure maintainer and end-user coach. Successful information system developers will need new self-concepts, accommodating the application of specialized technology but also addressing the material interests of the end-user class. Such indoctrination is fraught with moral implications. Are we attempting to educate the dominant class of a new hegemony? Is moral philosophy a necessary component to such education? Will the new hegemony and its moral bases satisfy the constraints and purposes of enlightened reason? Can these concepts be woven into a curriculum so as to live and excite?

Key words: philosophy, change, technology, ethics, education.
 

Ideology-Oriented Programming in Health Care

People who create information systems are stepping across a great divide: from instrument to purpose, from knowledge to value. Many information system development efforts fail�to be on time, under budget, or satisfactory to their users�not for lack of knowledge but for lack of equity. Even where the cause of failure appears to be ignorance, an inequitable distribution of knowledge may be involved. People need efficient, effective, and equitable systems and, as information technology grows increasingly efficient and effective, but none-the-less frequently fails to achieve intended effects, ideological dimensions of system development will receive increased attention. Onto this stage will wander graduates of educational programs that emphasize information technology and its role in "reengineering" work processes. Students aspiring to participate in this matrix of competing interests and ideas can benefit from discussion of fundamental roles for knowledge and value in systems development. Such conversation transcends mere ethical codes of professional etiquette and involves philosophical inquiry into the nature of technology, change, and morality.

Health care is one industry within which information technology will play a particularly important role in preserving or undermining material interests of particular social groups: due to the relative complexity and importance of medical information, acceleration of the rate at which health care is embracing technology to address cost and quality issues, and health care�s own history of ideologies and hegemonies. Many of the following concepts and issues can apply to other industries as well, so their discussion will occur in both health care specific and health care non-specific contexts.

Figure 1

The structure of this paper reflects the structure of Figure 1. There is analysis of information system development in the workplace from the perspective of conflicting sets of implicit assumptions about knowledge and value. This drives the assertion of a need for an explicit philosophical framework and ideology of health information systems development. Relevant traditions of ethics and moral philosophy are highlighted, including medical, communication, and feminist ethics. Finally, the student, who is both a customer (of the educator) and a product (to the employer) in a strategic planning sense, has relevant developmental characteristics important to any form of implicit or explicit indoctrination.
 

The Need for a Philosophical Framework

Like the proverbial US Cavalry, health information managers, computer and information scientists, medical and nursing informaticians, management and information engineers, chief information officers, academics, and a variety of management consultants are racing to combine disparate knowledge, skills, credentials, and reputations necessary to use information technology to change health care. However, acquiring computer, business, and clinical knowledge will not be enough to claim leadership of applying information technology to redesign of US health care systems. While each group plays catch-up with substance and appearance of other groups� expertise, disciplinary boundaries begin to blur and members should begin to ask themselves what they share. Health care professionals and students that seek to combine these disciplines will have to resolve conflicting assumptions about new health information systems.

Advances in information technology, and market forces encouraging its application, create unprecedented opportunity for individuals to renegotiate their organizational roles,1 as well as danger of becoming economically displaced. As information system development increasingly relies on sophisticated domain knowledge and intuitive, visually oriented, tools for constructing computer application interfaces and databases�and less on pure technological knowledge�the balance of power will shift away from technologists and toward end-users.2 Technologists will increasingly occupy the roles of infrastructure maintainer and end-user coach while end-users will increasingly develop their own applications.

The issue is no longer how to program an algorithm or how to hack together a relatively large piece of software. The issue is more and more domain knowledge. As computer use expands into broader areas, the know-how necessary to coordinate a range of technologies well is more and more on the applications side.3(p.19)And: The software aristocracy has long held control over all software development, including applications. This has been mostly out of necessity rather than choice. Those who benefit most from new or modified applications will have the ability and the motivation to take control of application development.4(p.175)Avoiding competition and encouraging cooperation will require new roles and changed people to fill them, which can benefit from discussion of interpretive frameworks within which to view progress. A philosophical framework (in effect an ideology) in which to make fundamental assumptions explicit about the interaction of technology, work, knowledge, and value can provide a needed sense of control, and contribute to psychological hardiness and resistance to stress.9 Some type of ideology is necessary for people to justify to themselves that what they are doing is the right thing. If not, then the work force will be passive, obstructive, nonproductive, and cynical about the goals of their work and the organization that employs them.6(p.587)Such interpretive frameworks do not arise complete and whole, to be recognized as correct and then adopted, rather, they begin as a conversation, which to be successful, must contain an element of "transcendental eloquence."7 This conversation is philosophical (seeking to pause and reflect about fundamental knowledge and value in health information systems), comparative (searching for a larger framework within which to compare different assumptions about health information systems, and professional and personal development), dialogic (attempting to conversationally create and explore rather than to persuade in debate), and critical (revealing methods and their limitations, such as possible biases that preserve masculine hegemony).
 

Conflicting Workplace World Views

The broadest categories for comparing information systems development philosophies are based on conflicting assumptions about the sources and purposes of knowledge and value, represented by the archetype engineer who attempts to describe and control, the facilitator who strives to understand and cause understanding, and the emancipator who asks whose interests are served and seeks justice.8,9

In the earliest and still most popular information systems development philosophy, an engineer describes the objective world (based on user requirements and system specifications) and mechanically translates the description into an information system. Traditional management information systems departments have often striven to realize this ideal, emphasizing control in the name of productivity. End-users do not always maximally contribute expertise and support.

Perceptions�that the previously described "objective" approach excludes participation and expertise of end-users�generated an opposing approach emphasizing subjectively and socially constructed knowledge.10 End-users should design information systems since theirs is the most important reality. Experts facilitate end-user understanding of their work environment (and each other) and provide easy-to-use tools to end-users for creation of their own information systems (for example, customized spreadsheets and desktop databases). End-users informally communicate and experiment with tools to negotiate a common understanding of each other and their work environment. Unfortunately, understanding does not guarantee success since people who understand each other very well may proceed inconsistently and continue to struggle for resources.

These objective and subjective philosophies clash when they influence health information systems development. For example, the engineer searches for a single health care enterprise-wide database model while the facilitator encourages multiple and perhaps inconsistent user-defined databases.

Historically, dialectical processes have played fundamental roles in philosophical accounts of historical change and ideology.11(p.83) Dialectical reasoning compares opposing conceptual systems (thesis and antithesis, respectively) and creates a new more sophisticated conceptual system (synthesis) by "arraying and comparing ideas after first having attempted to give each its most forceful expression."12(p.21) The engineer archetype can be associated with thesis (initial system to be defended) while the facilitator archetype can be associated with antithesis (opposing system). A new and more sophisticated archetype that incorporates valuable qualities from both the engineer and facilitator, while resolving apparent contradictions, is the synthesis. Such a synthesis is the emancipator, who appreciates both objective and subjective dimensions of complex human-machine cognitive systems and searches for contradiction to impel action and cause change. The emancipator opportunistically moves between engineer and facilitator roles while functioning as a self-designated change agent: a political actor whose agenda is justice.

The emancipator archetype can be interpreted in different ways, such as commitment to a "subversive" liberation theology in which hospital management is convinced of the potential for control and end-users of the potential for freedom, while siding with end-users. (This is not completely implausible. Militant end-users have replaced chief information officers.13) Another approach is to convince management of the potential for control and end-users of the potential for freedom, and then to eliminate the distinction between management and end-users by instituting self-managing teams.14 A technological synthesis is increased control over infrastructure such as database servers and data communication standards while increasing freedom at the desktop for the end-user to design their own applications.15(p.338)
 

Resource Traditions for Curricular Content

If resolution of conflicting assumptions about knowledge in health information systems development leads to values, where do they come from and what should they be? Amid dramatic and traumatic potential for change what shared meaning is worth the risk and pain? Good intentions are not enough. Assumptions about value can and do conflict, and understanding this conflict leads to moral philosophy.

As computing technology becomes technology for communication and organizational intervention, computer ethics will increasingly concern contributions to freely made and informed decisions concordant with personal and organizational values. "Freely," "informed," and "values" mean different things in different ethical systems, and different ethical systems can have different assumptions about the source of their own existence.16 For example, in one view, ethical principles evolved to protect us from each other and to facilitate cooperation. Other views involve ethical principles that are independent of individuals or communities (accessible through spiritual, religious, or rational mechanisms), ethical principles that are so situation specific as to defy generalization ("When in Rome, do as the Romans."), or even the view that ethical principles do not exist and that perceived principles are mere interpretations of emotional attitudes ("That�s revolting, it must be immoral").

Sensitivity to different ethical bases will be necessary for health care information system developers to communication with other constituencies (such as physicians and executive management). Three particularly relevant sources of moral theory are medical, communication, and feminist ethics, highlighted here because of need for a common language with physicians-as-moral philosophers (who directly or indirectly influence three quarters of health care expenditure), the importance of communication among converging constituencies from different disciplines (such as medicine, business, and information technology), and a requirement for reflection about gender-specific stereotypes prevalent in health care.

Four principles of medical ethics have been particularly influential in the development of modern moral philosophy17: beneficence (providing benefits while weighing the risks, for example, balancing benefits of accessible electronic medical data against risks of abuse), nonmaleficence (avoiding unnecessary harm, such as that due to negligent software practice), self-autonomy (respecting client wishes, which can conflict with beneficence, as when an patient or organization rejects help), and justice (such as fairly distributing benefits and burdens, respecting individual rights, and adhering to morally acceptable laws). These default principles can conflict with each other during applications in specific cases. However, people from different cultures, religions, and (notably) disciplines usually agree about these principles, although not necessarily about results of specific application. These principles are especially relevant to the health information system developer-as-moral philosopher because they are generally respected by physicians.

Scope of principle application is also important. For example, use of new information technology is intimately associated with the reengineering movement.18 To many health care workers, "reengineering" is synonymous with "layoffs." In a dilemma reminiscent of determining who will be saved by admittance to a lifeboat, organizations and departments are forced to triage employees by categorizing them as being engaged in value-added or nonvalue-added activities. The questions of "Who will benefit from this information system?", "Who will be harmed.", "Who will have a choice?", and "Are the opportunities and risks fairly distributed?" all involve, beyond outcomes and procedures for determining them, the question of "Who is the community?" This question of scope is particularly problematic during reduction of community due to diminished resources. Employee perception�of whether the rules are fair and applied to everyone who counts�will influence whether any information system (introduced during reengineering) is viewed as fundamentally good (and supported) or fundamentally bad (and resisted or sabotaged).

After arriving at moral equilibrium about goals of patient treatment or organizational intervention, consider interaction between power and communication. Power distorts communication because it can prevent the best argument (based on better marshaling of better evidence) from achieving the status of truth within a consensus building process. This potential for distortion leads to a need for speech communities that observe four principles of ethical communication19: each utterance should be comprehensible (a criteria violated by intimidating computer jargon), true (violated by sincerely offered misinformation), justified (not be intimidated by repercussions), and sincere (the speaker must believe their own statements). These principles can also conflict, as when an utterance about a health information technology is simplified to the point of containing a degree of untruth in order to be comprehensible.

As a necessary counter point, it must be acknowledged within any discussion of moral philosophy and health information technology, that health care historically suffers from a feminization of clerical work which began early this century.20 Women, disproportionately employed in labor-intensive occupations, are among the most vulnerable to displacement due to new technology in the workplace.21 Furthermore, some feminist writers have dismissed dispassionately rational and legalistic accounts of morality (such as those just offered) as being based on a fundamentally masculine psychology of moral development.22 In contrast, they offer moral theories based on a feminine psychology that emphasizes empathic, caring relationships within an extended metaphorical family. Other feminist theorists are suspicious of any account that assigns to women specialized roles of caring and nurturing, due to potential use in reinforcing a subordinate role for women in a sexist society.23

Medical, communication, and feminist ethics provide possible sources of concepts, principles, and insights pertinent to a philosophy of health information science. Medical ethics, with roots in a common historical culture shared by health care professionals, provides a framework for discussion of designing health information systems. Due to power�s effect on persuasion, ethical communication plays an important role in information systems development. Those who seek�or are sought out�to fill the role of emancipator need to ask themselves whose interests are, and have historically been, served.

Student Psychology of Moral Development

Having conducted a necessary analysis of workplace issues, and determined possible resource traditions for influencing curricular content, there remains the student. Students react toward moral dilemmas differently, but Perry24 and Kohlberg25 provide potential conceptual frameworks for understanding developmental differences.

In Perry�s first stage (dualism) students assume the existence of correct knowledge and the goal of acquiring it from respected authorities. These individuals distinguish between themselves as true believers and others as unbelievers. Change appears to come from "out there" in the world. The second stage (relativism) involves more tolerance of different view and opinions, such as those held by business, medically, or technologically-oriented constituencies. However, confused by a multiplicity of views, students become equivocal about what kinds of change are desirable. The final stage resolves their conflicting views through acceptance of personal responsibility, at their own risk, for choosing and acting upon their own set of assumptions. Change appears to spring from within.

Kohlberg addresses the psychology of moral development from the point of view of assumptions about, and contributions to, "just" communities. Attaining such community requires proceeding from an egocentric view of the world ("What is in it for me?") through a conventional view ("What do other people think?") to a postconventional view ("How influence what we, as a community, think?"). The progression is one of movement from a selfish and simple view of the world toward a selfless and complex contingent view.

From a curriculum design perspective, the challenge is to prepare students for system development in a workplace with conflicting world views through reliance on existing and new traditions of ethics and moral philosophy, with acknowledgment that each student may be at a different stages of moral development at different times. Early training might emphasize basic principles and stories to familiarize the student with the people and institutions about which the are to "care." Later material might address conflict among principles and people, moving students into the relativistic stage. Pressing students for advice on specific actions requires students to commit, to take the risk of being wrong, but to establish some form of provisional foundation to guide action.

Prior and on-going life experience, outside of school, can be a powerful catalyst. For example, volunteering can expose students to people they would otherwise encounter as abstract concepts (the "poor", the "sick", the "down-sized"). Particularly at the professional master�s level, where many students have family and work roles, search for meaning can be poignant. For example, someone who has had significant interaction with the health system as a patient, or as the relative of a patient, may, with addition of knowledge about how health care "really works" and information technology skills, become a powerful patient advocate (both in the sense of directly advising or representing patients and their families, and in designing patient-friendly information systems to help them manage their own health care).

Selectively, aspects of the student experience can be mapped to aspects of the end-user experience. For example, like potential end-users, students too, can be intimidated by the new technologies they are to master. In these contexts, at a moment of great frustration with a temporary obstacle to understanding or controlling new tools, one can step back and say "Remember this moment, someday you will be facing and reassuring someone else feels feels like you do now."

Advice given to medical students in medical ethics classes includes that of imagining that the patient has the physician�s medical knowledge: "What would the patient decide?" The notion of making oneself into an instrument for achieving another person�s goals may be misleading, since there are limits to our abilities, based on our own histories and implicit biases, to truly place ourselves into someone else�s skin. Furthermore, there are, perhaps, personal and professional moral absolutes that can contravene pure forms of instrumentality. Yet, there is a powerful insight here. To serve someone is to be someone, albeit imperfectly and temporarily. Becoming someone requires sympathetic familiarity, such as that acquired within an extended family sharing a metaphorical home.

In the case of an intersection of medical, business, and computer knowledge, three potential "homes" are schools or departments of medicine (or public health or health sciences etc.), schools of computer (or information or engineering science), or schools of business administration and management. Business and computer knowledge is instrumental to reengineering health care with information technology, and the metaphorical patient is the health care worker or end-user (or perhaps health care organization or system). Students need to absorb health care professional values implicitly over extended periods of time. They need to learn to "think" like managers and technologists, but to "feel" like health care workers and end-users. Just as departments of management information systems are housed in schools of management and business administration, departments of health information science should perhaps be housed in schools of health science or medicine.

To place this assertion into perspective, consider several phenomena in society at large. Daniel Bell26 argued that society�s horizontally-based class systems, with their potential for vertical conflict between layers, are being replaced by vertical divisions (such as manufacturing versus government versus health care) within which individuals share material interests. A janitor and CEO in one industry have more in common than janitors and janitors or CEO�s and CEO�s from different industries. Conflict for society�s resources will increasingly occur among vertical sectors. Health care and its interactions with other industries is an example of a sector which has recently experienced considerable attention from government, manufacturing, and other spheres, due to health care�s competition for societal resources.

Mirroring this trend from horizontal to vertical allegiance is decreasing membership in information technology professional organizations not tied to specific vertical industries. Meanwhile memberships are increasing in information systems professional associations allied to specific vertical industries such as health care.

Students who will use information technology to achieve clinical and administrative goals in health care need to be exposed, familiarized, and committed to health care as their primary home, if they are to be successful in thinking like technologists but feeling like health care providers. "Where one stands depends on where one sits." One�s values depend on one�s spiritual home. To serve health care end-users, students need, in addition to computer and management knowledge, to implicitly share with end-users important values that can best be created by building a common history of tradition and interaction. Students develop morally at different rates, so it cannot be simply a matter of providing information science basics and then topping them off with an "Intro to Health Care" gloss.

Students need to have daily lunch with other students in their clinical white coats (who will be their customers), to smell the distinctive antiseptic smells of the anatomy lab, and to take for granted the myriad of images, terminologies, attitudes, values, and smells that make health care unique. Thus, budding health information scientists, if they are to share a class consciousness with their customers, should be academically based in the same organizations that train their future customers, schools of medicine, health science, and other clinically oriented units.
 

Conclusion

Ideas are in perpetual conflict with each other, especially here and now, in discussions of health care system redesign. Increasingly, the conflicting ideas�resolution of which will determine the basis of future health care information technology communities�will be fundamentally philosophical and moral. It is not a question of choosing to address these ideas, which will confront any who attempt to adapt, or adapt to, new information technologies transforming health care. Rather, it is a question of whether these ideas can be intelligently, productively, and, yes, passionately discussed in conjunction with their confrontation. Success requires much soul searching, self-disclosure, and thoughtful interpretation of events in terms of underlying assumptions. Doing so links health information science to philosophy, and health information systems to their fundamental bases and justifications.

Responding to these challenges will require health information science to confront fundamentally differing assumptions, visions, metaphors, and ethical systems. Higher education has a strong tradition of thinking and articulating "big thoughts". Archetypes, dialectical conflict, and ethical traditions are that. They seem at once far removed from the sounds of battle and the facts on the ground, and yet, they have the potential to loom wherever one looks. The challenge for health information science educators is connect the big ideas "up there" to vivid circumstances "down here," and to make moral philosophy live for students who aspire to use technology and money to change health care.
 

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