Kraven på vårdens professioner och chefer är höga. De förväntas ge en god och säker vård på lika villkor till hela befolkningen, administrera, prioritera och arbeta kostnadseffektivt. Men hälso- och sjukvården fungerar inte som den ska. Arbetsmiljön är osund, sjuksköterskor lämnar yrket, vården är ojämlik och svårt sjuka patienter får vänta i långa köer. Detta gör att människors liv, hälsa och värdighet står på spel.

På spaning efter etik uppmärksammar tre nyckelgrupper av aktörer som genom sina beslut har ett stort inflytande över vårdens villkor: politiker, opolitiska chefstjänstemän och vårdgivarnas högsta chefer i landstingets ledningsorganisation. Hur ser de på sitt etiska ansvar för hälso- och sjukvården? Vilka etiska bedömningar och konsekvensanalyser gör de? Och vilken etisk kompetens fordras för att de ska kunna ta ett etiskt ansvar för vårdens villkor genom ledning, styrning och organisation på den regionala nivån – och därmed för att samhällsmedborgarna ska kunna känna tillit till att vården fungerar som den ska?

Boken är ett resultat av ett tvärvetenskapligt empirisk forskningsprojekt, finansierat av AFA Försäkring, som har bedrivits på Stockholms centrum för forskning om offentlig sektor, Score.

Background: By tradition, the Swedish health care system is based on a representative and parliamentary form of government. Recently, new management forms, inspired by market principles, have developed. The steering system is both national and regional, in that self-governing county councils are responsible for the financing and provision of health care in different regions. National and local documents regulating Swedish health care mention several ethical values, such as equity in health for the whole population and respect for autonomy and human dignity. It is therefore of interest to investigate the status of such ethical statements in Swedish health care management. Method: The aim of the present study was to investigate perceptions of the status of ethics in the daily work of politicians, chief civil servants and Chief Executive Officers (CEOs) from care-giver organizations in the county council of Stockholm. A qualitative method was used, based on inductive content analysis of individual interviews with 13 health care managers. Results: The content analysis resulted in four categories: Low status of ethics; Cost-effectiveness over ethics; Separation of ethics from management; and Lack of opportunities for ethical competence building. The informants described how they prioritized economic concerns over ethics and separated ethics from their daily work. They also expressed that they experienced that this development had been enforced by the marketization of the health care system. Further, they described how they lacked opportunities for ethical discussions, which could have helped develop their ethical competence. Conclusions: In order to improve the status of ethics in health care management, ethical considerations and analyses must be integrated in the regular work tasks of politicians, chief civil servants and CEOs; such as decision-making, budgeting and reform work. Further, opportunities for ethical dialogues on a regular basis should be organized, in order to improve ethical competence on the management level. New steering forms, less focused upon market principles, might also be needed, in order to improve the status of ethics in the health care management organization.

Purpose – The purpose of this paper was to explore what kind of ethical competence healthcare managers need in handling conflicts of interest (COI). The aim is also to highlight essential learning processes to develop healthcare managers’ ethical competence.

Design/methodology/approach – A qualitative study was performed. Semi-structured interviews with ten Swedish healthcare managers from different care providers were carried out twice and analysed through step-wise categorisation.

Findings – Four categories of COI were revealed and two ways (passive and active) in which COI were handled. Ethical guidelines did not help the healthcare managers to handle the COI, and none of the managers made use of any sort of systematic ethical analysis. However, certain ethical competence was of great importance to identify and handle COI, consisting of contextual understanding, rational emotions, some theoretical knowledge and a suitable language. Organising work so that ethical analysis can be carried out is of great importance, and top management needs to clearly express the importance of ethical competence and allocate resources to allow adequate learning processes.

Originality/value – This paper highlights the management level and focuses on how work-integrated learning-processes can enable ethical competence. Ethical competence at the management level is essential both to comply with the constitution and legal requirements regarding healthcare, and so that managers are able to analyse COI and justify their decisions.

While research concerning ethical competence in medical practice is frequent, ethical competence in health care management is less often studied. This article focuses ethical competence and its preconditions with regard to health care managers’ identification and handling of conflicts of interest. The article is based on empirical research. The aim is to highlight the importance of managers’ ethical competence and what such competence need to contain in order to promote ethical responsibility and a healthy working environment. Of great importance for success are having rational emotions, an adequate ethical language and communicative skills in order to promote dialogue. But the political and administrative control system also needs to clearly articulate the ethical dimensions of the managers’ task, allocate resources for training in ethics, and ensure that support systems and evaluation focus not only on finances but also on the value-rational aspects with regard to what the health care organization is aimed for.

Forskning som rör etisk kompetens bland medarbetare i vården är förhållandevis vanlig, medan etisk kompetens  bland vårdchefer knappt har studerats alls. Den här artikeln uppmärksammar etisk kompetens och dess handlingsförutsättningar när det gäller vårdchefer inom hälso- och sjukvården, särskilt med avseende på verksamhetschefers identifiering och hantering av intressekonflikter. Artikeln bygger på empirisk forskning och syftet är att uppmärksamma vikten av chefernas etiska kompetens och vad en sådan kompetens behöver innehålla för att främja etiskt ansvar och en hälsosam arbetsmiljö. Chefens tillgång till ett adekvat språk för etik, förmåga att utveckla rationella emotioner och kommunikativa färdigheter i syfte att främja dialog utgör centrala aspekter av den etiska kompetensen. Men de politiska och administrativa styrsystemen behöver också tydligt formulera de etiska dimensionerna av chefernas uppgift, avsätta resurser för utbildning i etik, och se till att stödsystem och utvärdering fokuserar inte bara på ekonomi utan också på värderationella aspekter med avseende på vad vårdorganisationenär avsedd för.

While research concerning ethical competence in medical practice is frequent, ethical competence in health care management is less often studied. This thesis focuses ethical competence and its preconditions, particularly with regard to health care managers’ identification and handling conflicts of interest. Based on the empirical analysis it also discusses what kind of ethical competence health care managers need, and how this competence can be developed in the organization. The study is based in action theory and takes an organizational pedagogical point of departure. Qualitative, semi-structured interviews were carried out twice with ten health care managers in the Stockholm region. Data were analysed using a thematic, step-wise method. The analysis revealed several examples of conflicts of interest and different ways in which they were managed. The all-embracing conflict involved weighing and prioritizing patients’ needs, patient safety, and work environment against political and economical goals. In most cases the informants did not manage to strike a balance between professional ethics and business management. The dominance of purposive/instrumental rationality tended to inhibit the managers’ ethical competence. At the same time, as shown by the analysis, some of the managers were able to use ethical competence to pursue value/belief-oriented rationality in achieving such a balance. Of great importance for success are having rational emotions and an adequate ethical language, and organizing for the task of handling conflict of interests in order to support action and provide qualifying experiences to learn from in the work processes. But the political and administrative control system also needs to clearly articulate the ethical dimensions of the managers’ task, allocate resources, and ensure that support systems and evaluation focus not only on finances but also on the value-rational aspects.