The following case studies illustrate how easily one’s conduct can breach ethi- cal standards. The aim of this article is to introduce the four principles and four behavioral standards of ethical conduct. While some ethical situations are not obviously right or wrong, others are more clear-cut. Each of the cases below illus- trates a specific ethical principle.

Case 1-Jeff is the Business Development Director for a national construction com- pany with a local office that specializes in healthcare construction. He notices that his company never receives notice of projects from one of the local hospitals. Although he visits with the director of facilities for the hospital, shares his company’s experi- ence and expertise, and participates in the fund-raising activities for the hospital, he realizes that his company never receives requests for proposals (RFPs). In one of his visits with the Director of Facilities, he asks her if there is a reason that his company is not considered. She reassures him that his company has an excellent reputation for safety and quality in construction, and that she will ensure that he receives an RFP in the future. Jeff is later informed by a colleague that the Director’s assistant previ- ously worked for a construction company and that the same company is highly favored by the hospital in spite of its lack of healthcare construction experience. Later it is revealed in the news that the president of the construction firm donated $1.5 million to the hospital’s foundation.

Case 2 -Big Name Hospital System has decided to have a design competition among architects for its new Heart Center, which will be the flagship, state-of-the-art hos- pital for the entire system. An RFP is sent out to a number of architectural teams with the terms for the design competition. The firms are notified that they will not be compensated for their design, that designs must meet certain space and budget cri- teria, and that the designs must be examples of evidence-based healing environments. The teams are given 4 months to complete their designs, and then they are expected to present the designs to the Executive Selection Team for Big Name Hospital System. The architects are expected to bring their updated space programs, schematic designs, and architectural renderings of how they envision the new Heart Center and evidence for their design features and solutions. After all of the architectural firms have pre- sented their prospective designs, the Executive Selection Team chooses two finalists. They inform the architectural teams that they like certain elements of their designs, but they request them to consider other design requirements and features that were presented by some of the architectural firms who were not selected as finalists. The executive team indicates that they really like the design presented by one of the previ- ous teams. They share the renderings and schematic designs of one of those teams to the finalists and ask them to take them into consideration in their final presentations for the project. Approximately a year later, Steve, who is the Managing Partner for a large architectural firm that was considered in the design competition but was not selected as one of the two finalists, notices that the new Heart Center for Big Name Hospital System has won a design award by a very prestigious organization. When he reviews the small schematic design and the rendering for the new Heart Center, he is shocked to realize that it is nearly identical to the design that his architectural firm submitted and presented to the executive team at Big Name Hospital System. Apparently the architectural firm selected for the project simply took his firm’s design and now was now receiving an award for that design.

Case 3 -The RFP for a replacement hospital for Shady Point Medical Center requires that each of the architectural teams indicate how they use evidence to support their design process and design solutions. The executive team for Shady Point Medical Center receives the proposals from three architectural firms, all of whom indicate that they have “vast experience” in evidence-based design. When the interviews occur, one of the questions is for the architectural firm to give an example of how they have used evidence to guide their design for previous project. Only one of the architectural firms was able to indicate that they used evidence published in the HERD Journal to guide their decisions about including both centralized and decentralized nursing stations in their final design and the rationale for that decision. The other two firms, although they indicated that they had experience in evidence-based design, were unable to give an example from any past projects.

Case 4- Catherine is the editor of a healthcare design journal. In her role as edi- tor, she has the power to decide which of the manuscripts submitted should be imme- diately accepted for peer review or sent back to the author with a rejection letter. On one occasion, she received a manuscript from an author with whom Catherine has had many disagreements in the past. She reviews the article and while it is not perfectly formatted according to the author guidelines for the journal, the content is relatively sound. At first Catherine is inclined to reject the article and send it back to the author, but upon self-reflection, she realizes that her decision to do so would not be appropriate. So she sends out the article to the reviewers for their consideration.

These four examples highlight a few of the ethical issues that surface in the healthcare industry and in healthcare design. The domain of “organizational ethics” includes not only the values endorsed by the organization, but also an organization’s business activities, marketing, billing, and its relationship to staff members and members of the community. All healthcare organizations have a compliance officer who ensures that all staff members, regardless of their position in the hierarchy of the organization, adhere to certain ethical behaviors and com- ply with legal, regulatory, and ethical standards (Society for Human Resource Management, 2013; The Office of Inspector General of the U.S. Department of Health & Human Services and The American Health Lawyers Association, ND). Most architectural companies also articulate specific organizational val- ues in their mission statement, which is shared with potential and actual clients.

The four cases above were examples of various breaches in ethical standards. The purpose of this editorial is to outline and define four ethical principles that form the cornerstone of ethical decision making, and commonly applied rules that create fairness in business relationships and specifically between healthcare organizations and design and construction firms.

The four principles that form the cornerstone of ethical decision making are (1) Autonomy, (2) Beneficence, (3) Non-maleficence, and (4) Justice (Butts & Rich, 2013). Autonomy refers to an individual’s right for self-determination and free- dom in decision making. Beneficence means doing good to others in providing benefit and value balanced against risk. Non-maleficence means to do no harm to others. Justice refers to being fair and giving equal treatment and consider- ation to all parties, including distribution of benefits, risks, and costs (Beau- champ & Childress, 2009; Cooper, 2010). One can readily see how these four principles of ethical decision making were breached in the previously described cases. In Case 1, the healthcare organization was not demonstrating justice, in that the decision makers did not give all equally experienced construction firms equal opportunity to compete for its projects. It is understood that firms that have undermined the trust of an organization or that have a poor reputation for completing projects safely, on time, and on budget may not be considered for future projects. However if favoritism is demonstrated toward one construction company among others who are equally qualified and experienced, a breach of justice occurs. This is particularly important when hospital decision makers have received certain favors such as gifts, dinners, entertainment, and even large donations to the hospital’s foundation, which would make them noncompliant with specific federal regulations.

Case 2 is also an example of unethical conduct on the part of the big name hospi- tal system and the architectural firm chosen for the new heart center. Both enti- ties demonstrated unethical conduct by using the intellectual property from the non-selected firm’s presentation materials, claiming it as their own, and publicly receiving acknowledgment for a design that they did not create. Big Name Hos- pital executives demonstrated unethical conduct in asking the two architectural finalists to use material that was not their own to use. This case is an example of malfeasance where the non-selected firm was actually harmed by the unethical conduct of both the hospital executives and the selected firm.

In addition to the four principles of ethical decision-making, there are several commonly applied ethical rules, including (1) Fidelity, (2) Veracity, (3) Con- fidentiality, and (4) Privacy (Cooper, 2010). Fidelity refers to being faithful to commitments and accountable for responsibilities. Veracity refers to telling the truth and not intentionally deceiving or misleading others. Confidentiality pro- hibits some disclosures of information that result from certain relationships among parties without the consent of the original source of the information. Privacy is a right of limited informational accessibility (Beauchamp & Chil- dress, 2009). In Case 3 above, one can see that claiming experience and exper- tise in evidence-based design without being able to demonstrate proof of such experience is a breach in veracity. Many firms claim to have experience in evi- dence-based design and yet are unable to articulate the steps of the process, give examples of previous projects using such an approach, or even define research terms. The term evidence-based design is sometimes used more as a marketing tool than as a process to guide design decisions.

Publishing in scholarly journals is also subject to ethical issues. Case 4 illustrates that that ethical behavior among editors of scientific journals can shape the growth and development of a science. Editors have the power to decide which manuscripts should be immediately rejected and which should be distributed among reviewers for consideration. It is possible for unethical editors to shape the development of the science by disseminating only those articles that support the editor’s personal perspective on issues. The peer-review system provides some protection against editorial biases.

Another ethical dilemma from this author’s perspective comes when there is a conflict regarding who should be listed as first, second, or third author on a par- ticular manuscript. The order of authorship can be viewed from multiple per- spectives and can create an ethical dilemma among authors if this important issue is not discussed prior to commencing work on a manuscript. Technically, all authors who have been involved in the conceptual development of an arti- cle, the review of literature, the research planning and implementation, and the actual writing of the article should be included as an author. The author who has contributed the most to an article should be listed first, but in some instances other authors may feel that they have contributed equally or contributed areas of greater value. Therefore, the order of authors also presents an ethical dilemma that should be discussed and finalized among the authors.

It is possible that some organizations, both hospitals and design firms, and indi- vidual researchers may elect not to publish certain results or design outcomes if they believe that the findings may negatively expose the organization. Indi- vidual researchers whose studies reveal findings that they did not expect may also decide to withhold dissemination. These actions are unfortunate because all findings, expected or unexpected, contribute to a growing body of knowledge.

Many of the cases discussed in this editorial are open for interpretation. As is usual in most ethical dilemmas, there are no precise answers to ethical problems; all cases can be viewed from multiple stakeholder perspectives. Ethics should give guidance as to how to act in business and personal relationships, and provide a value system and code of behavior that create a sense of integrity in organiza- tional practice. Great healthcare design is born out of a strong collaborative rela- tionship among healthcare representatives and the design team, a collaborative relationship which is built on trust, founded on integrity, and sealed in fidelity and veracity. The healthcare industry and healthcare design field must have con- fidence that the scholarly findings and evidence in their fields of knowledge are being disseminated with the help of editors who are fair and have a strong com- mitment to the peer review process and a sense of responsibility and account- ability to ensure that all content that meets author guidelines and the mission of the journal is considered for publication. The developing science depends on the fidelity and veracity of its academic and practice researchers, healthcare decision makers, designers, and journal editors.