In today's environment, healthcare executives are faced with making challenging and complex decisions that require balancing the current and future needs of the overall organization with various constituencies that serve and are served by the organization. Sometimes these decisions come about when healthcare executives are faced with making "promises" or revisiting previous promises made by executives. When this happens, new challenges can come about from the difficult task of weighing the needs of varied constituencies and the use of resources, not to mention the ethical responsibility to make such decisions.

Promises are verbal or written commitments made to another person or group of people. Promises can be formal written agreements, such as contracts, or informal agreements such as when a healthcare executive states to someone (or a group of people) an intention to do something. When the executive does the latter and recognizes that such a statement of intention will lead the person(s) to whom it is given to count on your following through, your statement of intention is a promise. Once made, adhering to a promise is a moral responsibility of the healthcare executive, even if made by one's predecessor.

Despite the moral responsibility that one ought to respect a promise, organizational circumstances may change sufficiently so that the promise should be reviewed, even though the promise may have become a long-standing tradition or expectation. This could be a situation regardless of whether the promise was made by the current healthcare executive or a prior executive in the same position.

However, because trust and honoring moral commitments are hallmarks of successful healthcare organizations, making, revising or rescinding a promise requires thoughtful consideration. A healthcare executive needs sufficient reasons for both making a promise and for breaking a promise. In the latter case, the violation or breaking of a promise without adequate reason leads to harm, not only to the person(s) to whom the promise was made, but also to the executive and the image of the healthcare organization.

Policy Position

Making a Promise

The American College of Healthcare Executives (ACHE) firmly believes that healthcare executives have an ethical responsibility to use a systematic, deliberative and thoughtful approach to decision making when making a promise to a person or a group of people. To ensure such an approach, the following questions should be considered:

• What are the circumstances surrounding the promise? Why is the promise being considered? Why now?

• What are the facts regarding the promise? Is the promise legally binding? What does legal counsel suggest?

• What are the relevant ethical considerations regarding the promise? Is there an ethical rationale for justifying the promise?

• What are the options, such as maintaining the promise, rescinding the promise or altering the promise? Will future CEOs be able to uphold this promise? Are there circumstances under which this promise can or should be revisited? If so, what are they?

• What are the implications (benefits and harms) surrounding the above option(s)? How certain are you of those implications?

• What are the perspectives of the stakeholders affected by the promise?

• Have you carefully reflected on the various options, including conducting a quantitative and qualitative analysis of each option and assessing both the short- and long-term ramifications of each option?

• After selecting a particular option, did you seek the appropriate approval, such as the board's?

• How is the promise going to be communicated and documented? Has this document been shared with the relevant stakeholders? Is it clear how future CEOs will know this promise exists?

Keeping or Rescinding a Promise

1. Making a Decision Regarding a Previous PromiseAfter clearly identifying and acknowledging the need to review whether a promise ought to be maintained, the following questions should be considered:

   • What are the circumstances surrounding the promise? Why was the promise made? Why is it being questioned now?

     What are the facts regarding the promise? Is the promise legally obligated? What does legal counsel suggest?

     What are the relevant ethical considerations regarding maintaining, revising or rescinding the promise? Is there an ethical rationale for justifying the rescinding or revising of the promise?

     What are the options, such as maintaining the promise, rescinding the promise or altering the promise?

     What are the implications (benefits and harms) surrounding each option? How certain are you of those implications?

     What are the perspectives of the stakeholders affected by the promise?

     Have you carefully reflected on the various options, including conducting a quantitative and qualitative analysis of each option and assessing both the short- and long-term ramifications of each option?

   • After selecting a particular option, did you seek the appropriate approval, such as the board's, giving the ethical grounding for the decision?

2. Implementing a Decision Regarding a Previous Promise

   Decisions to rescind or revise an existing promise should be communicated in a timely manner to all key stakeholders, including the rationale for the action. When decisions are made to revise or rescind a promise, a clear communication plan is advised.

   A comprehensive communication plan includes the following:

   • Identifying the key audiences and messages.

   • Choosing the appropriate spokesperson for the target audience.

   • Obtaining the affected stakeholder perspectives and feedback, including being prepared to justify the decision and respond to all questions of concern.

   • Considering the response if the decision was reported by the media.

   During the communication process, if concerns or ramifications concerning the action arise that were not previously considered, executives should consider whether to review their decision regarding the promise.

Whether making a promise or reviewing a previous promise, the best decision outcome will be achieved when thoughtful, systematic reasoning and transparency serve as the primary guides for executive behavior.

Common Morality: Deciding What to Do. Bernard Gert. Oxford: University Press 2004. (This is a general reference specifically related to the definition paragraph)

Approved by the Board of Governors of the American College of Healthcare Executives on March 24, 2006.