Ethical competence in the health care management system

In this project we explore ethical competence among three influential groups of actors in the health care management system: elected politicians in the county council, head administrators, and health care managers. We regard them as influential since the management level provides preconditions for ethically well-grounded decisions and practices on different levels in the health care system. The management level also establishes criteria for evaluating job performance and efficiency.

Swedish health care is based on representative and parliamentary government. It is collectively financed (mostly by income taxes) and care should be provided on grounds of need, and not based on position or economic status. The governance of health care in Sweden has changed from a profession-based system towards management control through market-emulating mechanisms, something often referred to as New Public Management (NPM).  NPM is built on a market logic, where results and profit are key targets, which are transferred to the public sector, which used to be characterized by a different logic, with core values such as democracy and equal rights. In addition, national equality and local self-government may come into conflict. Both principles are based in Swedish law, but they can be difficult to harmonize. This is an important background to the project which makes questions of ethical competence in health care management organization urgent. How do politicians and administrators reason and act?

Ethical competence is a key concept and defined as:
• The individual and collective ability to identify value conflicts and conflicts of interest in a given situation
• The ability to analyze consequences of actions, identify duties and principles, and to motivate decisions based in ethical arguments
• The taking into account of other values than economical ones

The study is interdisciplinary and explorative. It is based in action theory and takes an organizational pedagogical point of departure. The aim is to investigate how ethical competence is expressed and developed in different areas and arenas of decision-making in health care management. We will also explore how preconditions for ethical responsibility are shaped on the management level in the health care organization. Questions we ask: How are ethical questions dealt with in the daily work? How are value conflicts identified and handled? And what responsibility do the informants think they have regarding creating preconditions for ethics in the health care organization?

The study will be conducted at the County Council in Stockholm. Three studies are planned, using different methods:

1) Analysis of policy documents and statements, using a specifically designed matrix (text content analysis, based in theory)
2) Observation studies, taking field notes in arenas were decisions are made, for example in assembly meetings or committee meetings (content analysis; synthesized process using theory to reveal meanings)
3) Individual interviews with elected politicians in the county council, head administrators and managers in the healthcare organization, using a semi-structured interview guide (content analysis)


• SEK 3.2 millions from AFA Försäkring
• The project is placed at SCORE, Stockholm Centre for Organizational Research
• Main applicant and project leader: Dr Erica Falkenström
• Other project participants: Associate Professor Anna Höglund
• Starting time: October 2013/January 2014