The organizational context of ethical dilemmas: a role-playing simulation for the intensive care unit

The allocation of health care resources often requires decision makers to balance conflicting ethical principles. The resource-constrained intensive care unit (ICU) provides an ideal setting to study how decision makers go about their balancing act in a complex and dynamic environment. The author presents a role-playing simulation exercise which models ICU admission and discharge decision making. Designed for the class-room, the simulation engages a variety of ethical, managerial, and public policy issues including end-of-life decision making, triage, and rationing. The simulation is based on a sequence of scenarios or "decision rounds" delineating conditions in the ICU in terms of disposition of ICU patients, number of available ICU beds, prognoses of candidates for admission, and other physiological and organizational information. Students, playing the roles of attending physician, hospital administrator, nurse manager, triage officer, and ethics committee member, are challenged to reach consensus in the context of multiple power centers and conflicting goals. An organization theory perspective, incorporated into the simulation, provides insight on how decisions are actually made and stimulates discussion on how decision making might be improved.