One of the many problems of Africa can be associated with the lack of functional and effective organizational ethics. Organizational ethics became not only the ethical buzzword of the Western world in the late 20th century, but began to infuse healthcare organizations (HCOs) after the call by the joint commission for accreditation of healthcare organizations (JCAHO) in the USA in the early 70s [32]. However, the use and application of organizational ethics is not limited to HCOs. The term covers a wide area of organizational culture, including the conduct of business affairs; decision-making processes; actual and potential conflicts of interest; appropriate use and allocation of financial, technological, and human resources; and the relation of the organization's actual activities to its stated mission and values [33]. It also deals with issues of organizational architecture which refers to ethical decision making, performance evaluation and compensation of employees [34]. Proponents of organizational ethics within HCOs contend that an organization's ethical responsibilities differ in kind from the responsibilities of individuals who work for it or who are associated with it. According to Paul Schyve the paradigm foundation of organizational ethics is not only each practitioner's obligation to the patient, a focus that has dominated healthcare ethics from the time of Hippocrates. More recently, a second source of obligation has arisen with the growing recognition that patients have "rights" in their relationships with healthcare providers. This dual recognition of professional obligations and patients' rights has fostered awareness in the commission's (JCAHO) statements and standards that organizations have an obligation to act to support and respect patients' rights [35]. On the other hand, simply locating organizational ethics in the personal ethics of each practitioner and administrator leaves too much to the vicissitudes of individual character. Based on this, Schyve concluded that HCOs have only one real choice: they must respond to new ethical challenges associated with managed care in the 21st century [35]. While JCAHO has focused on the development of organizational mechanisms to address ethical problems in healthcare, Van Rensselaer Potter, the eminent scientist who coined the term 'bioethics' argues that, even in so-called organizational ethics, "individuals bear the responsibility" [36]. Potter is convinced that bioethics must also reach into all organizations, including public corporations and HCOs. However, he does not agree with the assignment of moral agency and responsibility to an organization itself, arguing that organizational "systems" and "processes," are the product of human action, and individuals cannot take moral refuge by laying blame on non-personal systems and processes [36]. This observation is very important for public organizations in Africa where the general attitude according to anecdotal evidence is that 'government business is nobody's business', an attitude which supports the kleptomania and corruption which are prevalent in public institutions in Africa today [27], generally characterized by laissez faire leadership [25] and personal gratification.
Individual virtue and organizational ethics
The central focus of virtue ethics is the character of the person. In the context of medical ethics, virtue ethics is concerned with the characteristics of a good doctor, and in the context of organizations it is concerned with good leadership. According to Aristotle, "virtue is a state of character, concerned with choice lying in a mean, that is, the mean relative to us" [37]. Therefore, an action is considered right if, and only if, it is what a virtuous agent would do in the circumstances. Where a virtuous agent is one who exercises good virtues; and virtue is a character trait which human beings need in order to flourish. Therefore virtue refers to the character of individuals, characteristics such as honesty, integrity, respect, courage, truth-telling, persistence, nobility etc. In the context of 'organizational ethics', virtue would refer to character of the individuals within the organization, especially organizational leadership. According to some arguments every organization has goals and a 'way of doing things' that may appear 'ethical' or 'unethical'. Institutional goals therefore shape its core values. Nevertheless, Potter reminds us that an organization's goals and culture came from somewhere. Therefore an organization's leaders and key staff cannot avoid the burden of responsibility for the organization's actions and moral climate. They must be proactive by identifying potential ethical problems, addressing them before they arise and responding appropriately when the organization acts unethically [36].
Improving organizational ethics in Africa
If organizations are to be guided by their missions while recognizing the need to improve profitability, then keeping a focus on the mission could direct leadership of such an organization to treat their employees with respect by acknowledging tough times and enlisting employee's aid in finding ways to achieve organizational goals. Therefore it has been suggested that organizations and individuals need each other to be ethical [33]. While medical ethics has been traditionally preoccupied with the interaction of doctors and their patients, vis-à-vis, the doctor-patient relationship, modern medical practice frequently occurs in a background of the non-medical management of HCOs, insurance and pharmaceutical companies who are driven by the profit motive [31]. This means that the ethical quality of health care may be broadly influenced by the ethics within HCOs, including healthcare insurance and pharmaceutical companies, other business entities or governments that are involved in the funding of healthcare, especially in the era of commercialization. In this context it has been postulated that "we can't have ethical health care without ethical organizations" [38]. It has been suggested that ethics within organizations can be addressed at several levels. These have been grouped into four categories as follows: (a) at the personal level, where issues affecting work-life balance, personal taxes etc. may need to be addressed. (b) At the organizational level where issues faced by employees and leadership such as strikes, retrenchment and cost cutting need to be addressed. (c) At the industrial level where situations encountered by professionals within organizations such as doctors, nurses, accountants, CEOs etc. need to be addressed. (d) Finally at the societal and external level where such as issues as globalization and climate change encountered by organizational leadership may need to be addressed [39]. All of these situations which can lead to conflicts in situational ethics create moral and ethical dilemmas within organizations associated with ethics as the "business of being human" [40]. Resolving these moral and ethical dilemmas within organizations especially in Africa, will require a systematic approach using well-established ethical guidelines such as utilitarianism, justice, rights, virtue ethics and principlism, rather than non systematic and non-rational approaches such as obedience, imitation, intuition, habit [41] or tribalism and nepotism. Factors which may lead to unethical behavior within organizations include the moral climate of society and the moral culture of business and industry [39]. Recent examples would include the unethical moral climate within the banking industry which led to the near collapse of the international banking enterprise in 2008 and the ENRON saga in the United States [42]. Questionable behaviors within such organizations which may have led to moral decline include amoral decision-making, unethical practices such as accepting illegality as standard behavior, lack of ethical leadership, overemphasis on profits and perceived pressure to meet goals, insensitivity towards subordinates and victimization of whistleblowers, together with inadequate formal ethics policies [39].
Therefore improving the ethical climate within organizations would include the introduction of written ethical codes and guidelines with distribution of these materials to all employees. These should be reinforced through frequent communications and training of employees and leadership, as well as the availability of ombudsmen and whistle-blower mechanisms for anonymous reporting of transgressions [39]. A general rule of thumb suggested for dealing with ethical dilemmas and moral obligations within organizations is that when two or more moral obligations are in conflict, it is advisable to use the stronger one. Further, when two or more ideals conflict or when ideals conflict with obligations, its best to honour the more important one. Finally, when there is an equal conflict between moral obligations or ideals, choose the one that produces the greatest good for the greatest number of people based on utilitarian principles [39]. To put in another way, one must always remember that though there may be many solutions to a particular ethical or moral dilemma. There are usually acceptable and non-acceptable solutions. Therefore, one must try always to choose the most acceptable solution when confronted with a particular moral or ethical dilemma in practice [41].