**2. The relationship between the healthcare system and ethical values**

that are typically philosophical and humanistic and ethics and another more pragmatic and

Since the 1990s, the doctrine has taken notable steps forward in the definition of the particular version of ethics, that is, business ethics, while at the same time, quite a few enterprises have begun to equip themselves with instruments for defining and measuring their ethical

The underlying reasons for explaining the investments of the healthcare system in this direction are still the subject of ongoing investigation, but the clues that identify the true prearranged and sought-after purpose in the growth and legitimacy of their reputation are precise and consistent while not omitting the inevitable and fundamental necessity for the enterprise

Today, in fact, many healthcare companies or systems are fully aware that it is in their best interest to manage their ethics as much as their economy and that it is wrong to consider the commitment of social responsibility within the government only as a purely moral concern

Healthcare systems have taken different paths in identifying, improving and communicating their ethical behaviour. So, alongside ethical codes, the entire sections of periodical reports have emerged publically in order to ascertain the progress of the enterprise on the path to social responsibility [6]. Business ethics improves the image and credibility of the company towards the community. Ethics also represents an element that creates value in the conduct

Since ethical behaviour represents a state of being of the individual in the economic-business institution, as well as the result of personal values and of the belief in the values that the enterprise has given itself in order to operate correctly, its nonquantitative, but rather purely qualitative connotation is evident. Nevertheless, the return in terms of image, credibility, loyalty, customer retention and fairness allows the identification, in proper corporate behaviour,

On the whole, therefore, the translation of the ethics of the enterprise in precise strategic objectives leads to defining its social strategy. Today, the healthcare system is given a new role by the society, which stands side by side with the by now "institutional" role of producing goods and services while creating wealth: it thus becomes an organism that must behave more responsibly in satisfying human values. It becomes a cell that works in a synergetic manner within the larger macroeconomic system [8]. Each arrangement, consequently, in addition to an economic function, must also fulfil a social function, through the right balance between the specific interests of single productive units and the general interests of the entire community. It is, therefore, from the attempt to meet the demand and the requests coming from the external environment, compatible with internal needs, that the origins of the ethical character of the healthcare system arise [9], which can be considered as an added value for

quantitative one, the profit-seeking management of an enterprise [2].

behaviour [3].

84 Social Responsibility

to generate profit [4].

of the business.

the system.

(and therefore, in some ways, optional) [5].

of a factor in the creation of value for the enterprise [7].

The healthcare system is an economic institution that carries out the instrumental function of the production of goods or services (e.g. diagnosis, treatment, rehabilitation, long-term care), essential for the satisfaction of needs. This means that it is construed as an institute of the social system, formed by a plurality of elements, instrumental in the resolution of problems connected to economic activity; as such it manifests behavioral rules and the institutional aims of creating lasting value [10].

The aim is justified by the observation that only the creation of value allows the healthcare system to endure. In fact, each enterprise, by organizing and implementing production, must try to use the acquired and available resources, in an economically efficient manner, creating products or services whose value, as assessed by market prices, is greater than the value of the resources used [11].

Value is created, therefore, when the benefit, incorporated in the products or services generated, is greater than the benefit consumed in the transformation phase.

In this way, the placement on the market of the products or services created, at an appropriate price, allows for the suitable compensation of all the production factors, including the production factors originating from capital and labour and the recovery of the financial resources to be allocated towards the buyback of the resources, necessary to reproduce the production cycle.

The centrality assigned to the aim of the creation of value is further developed, when taken into consideration that, in carrying out the instrumental function of production, the healthcare system represents a stable institution, equipped with its own structure and purpose. And as a permanent structure, it tends to perpetuate its own existence through the continuity of productive processes that only the long-term creation of value can ensure [12].

The characteristic of continuity is connected to that of autonomy, intended as the ability to find management conditions which determine a balanced operation, in such a way as to respect the long-lasting development constraints of the production activities. In this sense, the concept of autonomy is a qualification of the character of continuity.

The institutional aim of the creation of value requires, furthermore, the observation of the conditions of economy, that is, the ability to compensate and remunerate all the productive factors used, such as instrumental goods and services, and to reach a cash flow balance, in order to allow for the continuous succession of the productive cycles.

The aim of long-term creation of value, through the postulation of continuity and autonomy, introduces two elements into the analysis: future projection and the concept of a system. Enterprises are usually not founded with the sole purpose of carrying out a single economic operation of a speculative nature, but rather to become a complex economic unit, organized to fulfil productive processes over a long time span.

The irrefutable fact that the activities of an enterprise are projected into the future entails, though, that decisions are adopted in a state of uncertainty, given the variability of the conditions in which they are carried out. The investments required for carrying out productive cycles and the placement of the products or services rendered, in fact, occur based on trade relationships whose determinants depend upon market conditions, only partially influenced by the negotiating skills of the enterprise.

In this case, conditions of inefficiency and organizational disorder are formed within the cor-

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Considering this, it is obvious that the more the intervention of efficient and effective organizational practices becomes indispensable, the more it is necessary to constrain behaviour,

But these aims have an implementation perspective only if decision-making processes and operating procedures are developed guided by principles of fairness and transparency [14].

Furthermore, the procedure of corporate governance is consistent with the aim of the creation of value when the systematic use of accumulated resources is stimulated by behaviour that does not deplete with a simple economic trade, profit-driven exchange but creates well-being

The search for precision and certainty is based, therefore, on decisions in which rationality is limited—not everything is predictable; not everything is controllable—in which the calculation of pure economic convenience is accompanied by the influence of variables that react in

The legitimacy and the consistency of ethical values develop in this context, in which the reasons for the complexity are prevalent and in which the relevant meaning of the relationships

Ethical values, in essence, are intrinsic to the enterprise, contributing to guarantee certain presuppositions which are useful to any form of economic activity, such as trust and the practice

They are formed by the principles of fairness, reciprocity and impartiality by virtue of which the contribution of each is recognized and rewarded, in observance with the agreed upon

The reference to the rules is used to indicate the mandatory norms of a legal ordinance, as well as to customs and, more generally, behaviour that, in a given context at a given time, constitute accepted and valid criteria for the purpose of legitimizing human activity in an

The combination of the principles of fairness, reciprocity and impartiality gives concreteness to personal conduct, directing choices in such a way as to guarantee to those who contribute to the pursuit of institutional goals the proper reward in proportion to the contributions

It can be affirmed, therefore, that the healthcare system is ethical when it pursues the institutional goals, intentionally tending to create long-term value, respecting the rules and reacting

This structuring, based on ethical values within the business plan, permits the resolution of

fostering relationships that promote the cooperation and sharing of common goals.

porate system that lead to the loss of economic functionality.

and satisfying needs.

rules.

economic field.

a more complex relational dimension [15].

between the components of the corporate system emerge.

of behaviour aligned with the rules of general acceptance.

ceded and in the correct observance of the shared rules [16].

ambiguity that sometimes comes up when business ethics is discussed.

with fairness, reciprocity and impartiality.

The possibility of creating wealth is moreover subordinate to the ability of combining productive resources in an efficient manner.

Consequently, the periodical results of the production activities must be assessed, ex ante, as expected and possible, and ex post, only in the perspective viewpoint, as necessary, but not sufficient to guarantee the ability to preserve capital and income prospects in the mid- to long-term time frame.

The conditions of uncertainty, in essence, undermine behaviour geared towards obtaining the maximization of result in a short period, while it steers decisions towards a constant search for solutions to better safeguard and develop the financial structure, intended in its broadest sense, including even untapped resources in the quantitative datum, given their immateriality and non-transferability [13].

The meaning of these assertions can be found in the concept of system, which underlies business analysis.

Every enterprise is, in fact, made up of elements of different matters (material, immaterial), connected by more or less complex relationships. These relationships do not end in static ties, in an established direction; they constitute, instead, dynamic interactions which, if governed properly, modify the quality of the elements themselves, giving the whole a defined uniqueness.

The links between business components are capable of producing a general strengthening of the corporate system, since, by virtue of their actions, they in time settle into better standard procedures and organizational behaviour, gathering knowledge and information and developing experiences that lead to the resolution of given managerial problems.

Within the system, in essence, forces are created that find an expression in the system itself, in that they mature and act in a definite context and are, for this reason, not transferable.

The potential connected to these forces is difficult to assess, as it represents immaterial elements, included mostly in organizational structures, in know-how and in technological knowledge that describe the competences of the participants, at various levels, and relates them to the activity of the enterprise.

Nevertheless, just as these forces can give a decisive contribution to the tendential obtainment of the long-term creation of value, they constitute, if not wisely aimed, hindrance factors.

In fact, the relationships that form within the organizational structure and that involve, above all, a personal component become factors of inertia that limit the push for improvement and change when functionality and integration cannot be guaranteed.

In this case, conditions of inefficiency and organizational disorder are formed within the corporate system that lead to the loss of economic functionality.

The irrefutable fact that the activities of an enterprise are projected into the future entails, though, that decisions are adopted in a state of uncertainty, given the variability of the conditions in which they are carried out. The investments required for carrying out productive cycles and the placement of the products or services rendered, in fact, occur based on trade relationships whose determinants depend upon market conditions, only partially influenced

The possibility of creating wealth is moreover subordinate to the ability of combining produc-

Consequently, the periodical results of the production activities must be assessed, ex ante, as expected and possible, and ex post, only in the perspective viewpoint, as necessary, but not sufficient to guarantee the ability to preserve capital and income prospects in the mid- to

The conditions of uncertainty, in essence, undermine behaviour geared towards obtaining the maximization of result in a short period, while it steers decisions towards a constant search for solutions to better safeguard and develop the financial structure, intended in its broadest sense, including even untapped resources in the quantitative datum, given their immaterial-

The meaning of these assertions can be found in the concept of system, which underlies busi-

Every enterprise is, in fact, made up of elements of different matters (material, immaterial), connected by more or less complex relationships. These relationships do not end in static ties, in an established direction; they constitute, instead, dynamic interactions which, if governed properly, modify the quality of the elements themselves, giving the whole a defined uniqueness.

The links between business components are capable of producing a general strengthening of the corporate system, since, by virtue of their actions, they in time settle into better standard procedures and organizational behaviour, gathering knowledge and information and devel-

Within the system, in essence, forces are created that find an expression in the system itself, in

The potential connected to these forces is difficult to assess, as it represents immaterial elements, included mostly in organizational structures, in know-how and in technological knowledge that describe the competences of the participants, at various levels, and relates

Nevertheless, just as these forces can give a decisive contribution to the tendential obtainment of the long-term creation of value, they constitute, if not wisely aimed, hindrance factors.

In fact, the relationships that form within the organizational structure and that involve, above all, a personal component become factors of inertia that limit the push for improvement and

that they mature and act in a definite context and are, for this reason, not transferable.

oping experiences that lead to the resolution of given managerial problems.

change when functionality and integration cannot be guaranteed.

by the negotiating skills of the enterprise.

tive resources in an efficient manner.

long-term time frame.

86 Social Responsibility

ness analysis.

ity and non-transferability [13].

them to the activity of the enterprise.

Considering this, it is obvious that the more the intervention of efficient and effective organizational practices becomes indispensable, the more it is necessary to constrain behaviour, fostering relationships that promote the cooperation and sharing of common goals.

But these aims have an implementation perspective only if decision-making processes and operating procedures are developed guided by principles of fairness and transparency [14].

Furthermore, the procedure of corporate governance is consistent with the aim of the creation of value when the systematic use of accumulated resources is stimulated by behaviour that does not deplete with a simple economic trade, profit-driven exchange but creates well-being and satisfying needs.

The search for precision and certainty is based, therefore, on decisions in which rationality is limited—not everything is predictable; not everything is controllable—in which the calculation of pure economic convenience is accompanied by the influence of variables that react in a more complex relational dimension [15].

The legitimacy and the consistency of ethical values develop in this context, in which the reasons for the complexity are prevalent and in which the relevant meaning of the relationships between the components of the corporate system emerge.

Ethical values, in essence, are intrinsic to the enterprise, contributing to guarantee certain presuppositions which are useful to any form of economic activity, such as trust and the practice of behaviour aligned with the rules of general acceptance.

They are formed by the principles of fairness, reciprocity and impartiality by virtue of which the contribution of each is recognized and rewarded, in observance with the agreed upon rules.

The reference to the rules is used to indicate the mandatory norms of a legal ordinance, as well as to customs and, more generally, behaviour that, in a given context at a given time, constitute accepted and valid criteria for the purpose of legitimizing human activity in an economic field.

The combination of the principles of fairness, reciprocity and impartiality gives concreteness to personal conduct, directing choices in such a way as to guarantee to those who contribute to the pursuit of institutional goals the proper reward in proportion to the contributions ceded and in the correct observance of the shared rules [16].

It can be affirmed, therefore, that the healthcare system is ethical when it pursues the institutional goals, intentionally tending to create long-term value, respecting the rules and reacting with fairness, reciprocity and impartiality.

This structuring, based on ethical values within the business plan, permits the resolution of ambiguity that sometimes comes up when business ethics is discussed.

In particular, the observation that the goals of long-term creation of value are a function of the achievement of economy and the harmony between the forces of the corporate system, and of the corporate system along with the higher-level systems that operate in the environmental context, leads to certain considerations.

and organizational abilities are produced in the enterprise, which transform, with time, into

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The healthcare system is ethical when it pursues the aim of creating long-lasting value, acting

In this way, the enterprise carries out its instrumental function of creating economic goods that are able to satisfy the material necessities of society while at the same time respecting the

Obviously, the modern healthcare system is not asked to do charity work but to face a new challenge: combining profit, which is, in fact, its *raison d'être,* with respect and the safeguard of certain fundamental ethical values, contributing, in a decisive manner, to the economic, social and sanitary development of the entire associated community. Its economic action requires

Consequently, when it is claimed that ethics is necessary and useful, this means that the diffusion of ethical values contributes towards the long-term creation of value. In this sense, ethics is "worthwhile." The opposite would be true when the appeal to initiatives that try to demonstrate the sharing of proper and transparent behaviour reacts only to the objective of obtaining superficial consensus about corporate policies, hiding the real intention of taking advantage of only the image dividend, and leaves the concrete business conduct unaltered.

Ethical values acquire relevance since they are integral to the characteristics of vital processes of the enterprise; they contribute towards limiting the field of economically convenient alternative choices, by classifying both individual and organizational behaviors that confer upon

**3. Business and economic conditions and ethical premises in relation** 

Both economics and ethics propose to determine principles of behaviour in human actions, but while the former's principle aim is the activity of production and distribution of wealth, the latter proposes the universal nature of its principles, which become applicable in any con-

Business and economic theory, since its origins, orients itself to the search for the condition of existence of complex subjects such as enterprises, whose continuity is guaranteed not only by economic and financial balance but also by the degree of compatibility between external systems and the internal components, where human activity covers the nature of centrality

The importance of a functional dialog between ethics and the world of enterprises emerges even if the analysis is incorporated in productive organizations, considering the profound transformations that confer new characteristics and modify traditional structures. It is now an

economic capital.

with fairness, reciprocity and transparency.

**to the healthcare system**

text where human actions develop.

more and more [18].

entirety of the ethical values placed at the base of social behaviour.

behavioral reliability; ethical values become an integrated part of the model.

the corporate system the ability to obtain the conditions of perdurability [17].

To begin with, the fact that in the enterprise's divergent, institutional and economic interests converge does not transform the aim of the enterprises that remain anchored, in a social and economic context framework, to the creation of wealth.

The often conflicting claims and demands that converge within the enterprise due to the nature of the activity carried out, attributed to the creation and subsequent distribution of wealth, cause a series of possible conflicts. To ensure that everybody wins, the conflict must be regulated by a mutual recognition of separate requests, through the sharing of ethical values (fairness, reciprocity, impartiality).

This does not mean that the enterprise is transformed into a generic concept of communal good, but that the institutional aim (long-term creation of value) operates within an economic dimension; economic institutions consist of individuals; their enterprises bring in requests, culture, morality and their personal values. Rightly so, one speaks of "the relativity of ethical behaviour in both space and time" [28]. In fact, culture and requests are from different areas and countries with consequential diversity in the behaviour of individuals. Ethics present in a healthcare system cannot be the same that can be found in socio-economic contexts external to it. As the markets expand until they have merged together in a single scenario in which nations or continents represent only a geographical declination, they have consequently reversed the relationships between production and consumption, passing from productive logic to that of satisfying clients in terms of greater services offered, correctness and transparency, but, above all, the importance of image.

The healthcare system is no longer capable of carrying out its activity without taking into consideration its own behaviour. Its outward image has become more and more important, even being, in some cases, a factor of success or failure. Just as analysts require clear technical information in order to correctly evaluate the assets and financial situation, in the same manner, the wider consumer market sees this effort of business clarity more positively, recognizing not only the ability to manage truthfully but above all the greater value tied to the security of facing a subject with whom to negotiate, reducing within negotiations the uncertainty of information.

Transparency is not only external to the enterprise but also internal to it, so much so that there are many cases of change in governance in order to simplify and clarify the relationships between the various people that operate within the organization and all the stakeholders.

The fundamental principles of economic-business analysis confer upon time, and the systematic vision is of importance to analyze the vital processes of the healthcare system.

In this context, ethical values are basic, as, on one hand, they introduce the trust and fairness necessary to cement any relationship into the long term, and on the other hand, they determine indispensable conditions so that the processes of accumulation of technological know-how and organizational abilities are produced in the enterprise, which transform, with time, into economic capital.

In particular, the observation that the goals of long-term creation of value are a function of the achievement of economy and the harmony between the forces of the corporate system, and of the corporate system along with the higher-level systems that operate in the environmental

To begin with, the fact that in the enterprise's divergent, institutional and economic interests converge does not transform the aim of the enterprises that remain anchored, in a social and

The often conflicting claims and demands that converge within the enterprise due to the nature of the activity carried out, attributed to the creation and subsequent distribution of wealth, cause a series of possible conflicts. To ensure that everybody wins, the conflict must be regulated by a mutual recognition of separate requests, through the sharing of ethical values

This does not mean that the enterprise is transformed into a generic concept of communal good, but that the institutional aim (long-term creation of value) operates within an economic dimension; economic institutions consist of individuals; their enterprises bring in requests, culture, morality and their personal values. Rightly so, one speaks of "the relativity of ethical behaviour in both space and time" [28]. In fact, culture and requests are from different areas and countries with consequential diversity in the behaviour of individuals. Ethics present in a healthcare system cannot be the same that can be found in socio-economic contexts external to it. As the markets expand until they have merged together in a single scenario in which nations or continents represent only a geographical declination, they have consequently reversed the relationships between production and consumption, passing from productive logic to that of satisfying clients in terms of greater services offered, correctness and transpar-

The healthcare system is no longer capable of carrying out its activity without taking into consideration its own behaviour. Its outward image has become more and more important, even being, in some cases, a factor of success or failure. Just as analysts require clear technical information in order to correctly evaluate the assets and financial situation, in the same manner, the wider consumer market sees this effort of business clarity more positively, recognizing not only the ability to manage truthfully but above all the greater value tied to the security of facing a subject with whom to negotiate, reducing within negotiations the uncertainty of

Transparency is not only external to the enterprise but also internal to it, so much so that there are many cases of change in governance in order to simplify and clarify the relationships between the various people that operate within the organization and all the stakeholders.

The fundamental principles of economic-business analysis confer upon time, and the system-

In this context, ethical values are basic, as, on one hand, they introduce the trust and fairness necessary to cement any relationship into the long term, and on the other hand, they determine indispensable conditions so that the processes of accumulation of technological know-how

atic vision is of importance to analyze the vital processes of the healthcare system.

context, leads to certain considerations.

88 Social Responsibility

(fairness, reciprocity, impartiality).

ency, but, above all, the importance of image.

information.

economic context framework, to the creation of wealth.

The healthcare system is ethical when it pursues the aim of creating long-lasting value, acting with fairness, reciprocity and transparency.

In this way, the enterprise carries out its instrumental function of creating economic goods that are able to satisfy the material necessities of society while at the same time respecting the entirety of the ethical values placed at the base of social behaviour.

Obviously, the modern healthcare system is not asked to do charity work but to face a new challenge: combining profit, which is, in fact, its *raison d'être,* with respect and the safeguard of certain fundamental ethical values, contributing, in a decisive manner, to the economic, social and sanitary development of the entire associated community. Its economic action requires behavioral reliability; ethical values become an integrated part of the model.

Consequently, when it is claimed that ethics is necessary and useful, this means that the diffusion of ethical values contributes towards the long-term creation of value. In this sense, ethics is "worthwhile." The opposite would be true when the appeal to initiatives that try to demonstrate the sharing of proper and transparent behaviour reacts only to the objective of obtaining superficial consensus about corporate policies, hiding the real intention of taking advantage of only the image dividend, and leaves the concrete business conduct unaltered.

Ethical values acquire relevance since they are integral to the characteristics of vital processes of the enterprise; they contribute towards limiting the field of economically convenient alternative choices, by classifying both individual and organizational behaviors that confer upon the corporate system the ability to obtain the conditions of perdurability [17].
