BC Assuring the Quality of Care Discussion

Select one of the ethical issues listed below. Assume the ethical issue that you select has been brought to your attention as the chief operating officer of a hospital (e.g., breach of patient confidentiality, lack of choices presented to a patient for treatment options, intentional rationing of services to save money, etc.). Then, briefly describe the hypothetical situation and at least one mechanism (remedy) for resolving a breach of the identified ethical issue from a healthcare administrator’s perspective.

Ethical issues (Select One)

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Rationing      of health services.

Patient      privacy and confidentiality.

Patient      choice of provider and facilities.

Legal      rights of an individual vs. public health perspective to protect society.

Reminder for requirements: a minimum of 250 words (main post) and three scholarly sources.

1,500 word count and there is a total of 6 questions each (not including in-text citation and references as the word count), a minimum of 4 scholarly sources are required in APA format. For the 4 scholarly sources, one from the textbook that’s posted below and the other two from an outside source . Let’s be sure to write it in own work 100% and give appropriately when using someone’s else work. Under no circumstances use any direct quotes. Any directly quoted or copied material will result in a zero for the assignment.

  • Reference for textbook attached:
  • Williams, S. J., & Torrens, P. R. (2008). Introduction to health services (7th ed.). Clifton Park, NY: Thomson Delmar Learning.

  • Knowledge: What are the two key differences between medical / personal ethics and public health ethics?
  • Comprehension: What do you understand about the conflicting interests (not conflict of interest) between what is good for the greater whole as compared to the good of an individual?

  • Application: Give an example of a competing priority when the good of society is favored over the good of an individual. Is there a case / example of an instance when the good of the individual is more important than the good of the public? Be specific.
  • Analysis: What are the root causes of the conflict that can occur between medical / individual ethics and public health ethical standards? Do a comparative analysis on the ethics of privacy between public health ethics and medical ethics

  • Evaluation: What are the pros and cons of your new idea? How would you convince others that your idea offers a better solution? What are the unintended consequences of your idea?
  • Synthesis: Offer a new and unique solution that might mitigate the conflicts of interest. Why is your idea new? What are the implications for the benefits of conflict?

    CHAPTER 15
    Ethical Issues in Public Health
    and Health Services*
    Pauline Vaillancourt Rosenau and Ruth Roemer
    CHAPTER TOPICS
    R
    I
    C
    A
    R
    D
    ,
    LEARNING OBJECTIVES
    Overarching Public Health Principles: Our
    Assumptions
    Upon completing this chapter, the reader
    should be able to
    A
    D
    Ethical Issues in Economic Support
    Ethical Issues in Organization of Services
    R
    Ethical Issues in Management of Health
    I
    Services
    Ethical Issues in Delivery of Care E
    Ethical Issues in Assuring Quality N
    of Care
    Mechanisms for Resolving Ethical Issues
    N
    in Health Care
    E
    Ethical Issues in Developing Resources
    1. Appreciate the central role of public health
    ethical concerns in health policy and
    management.
    2. Understand ethics issues with regard to the
    development and distribution of, and payment for, services, and with regard to the
    organization, management, assessment,
    and delivery of services.
    3. Acquire a framework for ethical analysis
    of issues within health services systems.
    4. Be a humanistic as well as technically
    adept participant in the health services
    field.
    1
    9
    0
    2
    T
    S
    *From Changing the U.S. Health Care System, 3rd Ed. (pp. 643–673), by R. M. Andersen, T. H. Rice, and G. F. Kominski, 2007,
    San Francisco: Jossey-Bass. Copyright 2007 by John Wiley & Sons, Inc. Reprinted with permission of John Wiley & Sons, Inc.
    321
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    PART FIVE Assessing and Regulating Health Services
    322
    The cardinal principles of medical ethics1—
    autonomy, beneficence, and justice—apply in public health ethics but in somewhat altered form.
    Personal autonomy and respect for autonomy are
    guiding principles of public health practice as well
    as of medical practice. In medical ethics, the concern is with the privacy, individual liberty, freedom
    of choice, and self-control of the individual. From
    this principle flows the doctrine of informed consent. In public health ethics, autonomy, the right of
    privacy, and freedom of action are recognized insoR
    far as they do not result in harm to others. Thus,
    from a public health perspective, autonomy may Ibe
    subordinated to the welfare of others or of society
    C
    as a whole.2
    A
    Beneficence, which includes doing no harm, promoting the welfare of others, and doing good, isRa
    principle of medical ethics. In the public health
    D
    context, beneficence is the overall goal of public
    health policy and practice. It must be interpreted
    ,
    broadly, in light of societal needs, rather than narrowly, in terms of individual rights.
    Justice—whether defined as equality of opportuA
    nity, equity of access, or equity in benefits—is the
    D
    core of public health. Serving the total population,
    public health is concerned with equity among
    R
    various social groups, with protecting vulnerable
    I
    populations, with compensating persons for sufferE
    ing disadvantage in health and health care, and
    with surveillance of the total health care system. As
    N
    expressed in the now-classic phrase of Dr. William
    N
    H. Foege, “Public health is social justice.”3
    This chapter concerns public health ethics as disE
    tinguished from medical ethics. Of course, some
    overlap exists between public health ethics and
    medical ethics, but public health ethics, like public
    1
    health itself, applies generally to issues affecting
    9
    populations, whereas medical ethics, like medicine
    itself, applies to individuals. Public health involves
    0
    a perspective that is population-based, a view of
    conditions and problems that gives preeminence2to
    the needs of the whole society rather than excluT
    sively to the interests of single individuals.4
    S
    Public health ethics evokes a number of dilemmas, many of which may be resolved in several
    ways, depending on one’s standards and values.
    The authors’ normative choices are indicated. Data
    and evidence are relevant to the normative choices
    involved in public health ethics. We refer the reader
    to health services research wherever appropriate.
    To illustrate the concept of public health ethics,
    we raise several general questions to be considered
    in different contexts in this chapter5:







    What tensions exist between protection of the
    public health and protection of individual
    rights?
    How should scarce resources be allocated and
    used?
    What should the balance be between expenditures and quality of life in the case of chronic
    and terminal illness?
    What are appropriate limits on using expensive
    medical technology?
    What obligations do health care insurers and
    health care providers have in meeting the rightto-know of patients as consumers?
    What responsibility exists for the young to finance health care for older persons?
    What obligation exists for government to protect the most vulnerable sectors of society?
    We cannot give a clear, definitive answer that is
    universally applicable to any of these questions. Context and circumstance sometimes require qualifying
    even the most straightforward response. In some
    cases, differences among groups and individuals may
    be so great and conditions in society so diverse and
    complex that no single answer to a question is possible. In other instances, a balance grounded in a public health point of view is viable. Sometimes there is
    no ethical conflict at all because one solution is
    optimal for all concerned: for the individual, the
    practitioner, the payer, and society: For example, few
    practitioners would want to perform an expensive,
    painful medical act that was without benefit and
    might do damage. Few patients would demand it,
    and even fewer payers would reimburse for it. But in
    other circumstances, competition for resources poses
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    a dilemma. How does one choose, for example, between a new, effective, but expensive drug of help to
    only a few, or use of a less-expensive but less-effective
    drug for a larger number of persons? The necessity
    for a democratic, open, public debate about rationing in the future seems inevitable.
    Even in the absence of agreement on ethical assumptions, and facing diversity and complexity that
    prohibit easy compromises, we suggest mechanisms
    for resolving the ethical dilemmas in health care do
    exist. We explore these in the concluding section of
    R
    this chapter.
    A word of caution: space is short andI our topic
    complex. We cannot explore every dimension of
    C
    every relevant topic to the satisfaction of all readers.
    A whose
    We offer here, instead, an introduction
    goal is to awaken readers—be they practitioners, reR
    searchers, students, patients, or consumers—to the
    D to reethical dimension of public health. We hope
    mind them of the ethical assumptions that
    , underlie
    their own public health care choices. This chapter,
    then, is limited to considering selected ethical issues in public health and the provision of
    A personal
    health services. We shall examine our topic by way
    D developof components of the health system: (1)
    ment of health resources, (2) economic
    R support,
    (3) organization of services, (4) management of serI of the
    vices, (5) delivery of care, and (6) assurance
    6
    quality of care.
    E
    N
    N
    E
    OVERARCHING PUBLIC
    HEALTH PRINCIPLES:
    OUR ASSUMPTIONS 1
    9
    We argue for these general assumptions of a public
    0
    health ethic:


    2 need,
    Provision of care on the basis of health
    without regard to race, religion, gender,
    T sexual
    orientation, or ability to pay
    S
    Equity in distribution of resources, giving due
    regard to vulnerable groups in the population
    323
    (ethnic minorities, migrants, children, pregnant
    women, the poor, the handicapped, and others)

    Respect for human rights—including autonomy,
    privacy, liberty, health, and well-being—keeping
    in mind social justice considerations
    Central to the solution of ethical problems in
    health services is the role of law, which sets forth
    the legislative, regulatory, and judicial controls of
    society. The development of law in a particular field
    narrows the discretion of providers in making ethical judgments. At the same time, law sets guidelines
    for determining policy on specific issues or in individual cases.7
    ETHICAL ISSUES IN
    DEVELOPING RESOURCES
    When we talk about developing resources, we
    mean health personnel, facilities, drugs and equipment, and knowledge. Choices among the kinds of
    personnel trained, the facilities made available, and
    the commodities produced are not neutral. Producing and acquiring each of these involve ethical
    assumptions, and they in turn have public health
    consequences.
    The numbers and kinds of personnel required
    and their distribution are critical to public health.8
    We need to have an adequate supply of personnel
    and facilities for a given population in order to
    meet the ethical requirements of providing health
    care without discrimination or bias. The proper
    balance of primary care physicians and specialists
    is essential to the ethical value of beneficence so
    as to maximize health status. The ethical imperative
    of justice requires special measures to protect the
    economically disadvantaged, such as primary care
    physicians working in health centers. The imperfect
    free market mechanisms employed in the United
    States to date have resulted in far too many specialists relative to generalists. Other modern western
    countries have achieved some balance, but this has
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    324
    involved closely controlling medical school enrollments and residency programs.
    At the same time, the ethical principle of autonomy urges that resource development also be diverse enough to permit consumers some choice of
    providers and facilities. Absence of choice is a form
    of coercion. It also reflects an inadequate supply.
    But it results, as well, from the absence of a range
    of personnel. Patients should have some—though
    not unlimited—freedom to choose the type of care
    they prefer. Midwives, chiropractors, and other efR
    fective and proven practitioners should be available
    if health resources permit it without sacrificing
    I
    other ethical considerations. The ethical principle
    C
    of autonomy here might conflict with that of eqA
    uity, which would limit general access to specialists
    in the interest of better distribution of health care
    R
    access to the whole population. The need for ample
    D
    public health personnel is another ethical priority,
    necessary for the freedom of all individuals to enjoy
    ,
    a healthful, disease-free environment.
    Physician assistants and nurses are needed, and
    they may serve an expanded role, substituting for
    A
    primary care providers in some instances to alleviD
    ate the shortage of primary care physicians, especially in underserved areas. But too great a reliance
    R
    on these providers might diminish quality of care if
    I
    they are required to substitute entirely for physicians, particularly with respect to differential diagE
    nosis.9 The point of service is also a significant
    N
    consideration. For example, effective and expanded health care and dental care for children
    N
    could be achieved by employing the school as a
    E
    geographic point for monitoring and providing
    selected services.
    Health personnel are not passive commodities,
    1
    and freedom of individual career choice may conflict with public health needs. Here autonomy 9of
    the individual must be balanced with social justice
    0
    and beneficence. In the past, the individual’s deci2
    sion to become a medical specialist took precedence over society’s need for more generalists.TA
    public health ethic appeals to the social justice inS
    volved and considers the impact on the population.
    A balance between individual choice and society’s
    PART FIVE Assessing and Regulating Health Services
    needs is being achieved today by restructuring
    financial compensation for primary care providers.
    Similarly, in the United States an individual
    medical provider’s free choice as to where to practice medicine has resulted in underserved areas,
    and ways to develop and train health personnel for
    rural and central city areas are a public health priority. About 20 percent of the U.S. population lives
    in rural communities, and four in ten do not have
    adequate access to health care. Progress has been
    made in the complex problem of assuring rural
    health clinics, but providing for the health care of
    rural America remains a problem. It challenges efforts at health care reform as well.10 Foreign medical graduates are commonly employed in underserved urban centers and rural areas in the US
    today but this raises other ethics questions. Is it just
    to deprive the citizens of the country of origin of
    these practitioners of their services?11
    An important issue in educating health professionals is the need to assure racial and ethnic diversity in both the training and practice of health professionals. A series of court decisions and state
    initiatives have, with one exception, seriously limited admissions of minority students to professional schools.
    In 1978, the US Supreme Court in the Bakke
    case invalidated a quota system in admissions to
    medical schools, but provided that race could be
    considered as one factor among various criteria for
    admission.12 In 1996, the Court of Appeals for the
    Fifth Circuit in the Hopwood case, in considering
    admission policies for the University of Texas Law
    School, held unconstitutional an preference based
    on race.13 In 2003, the US Supreme Court made a
    sharp turn and in two cases involving affirmative
    action policies at the University of Michigan upheld an individualized policy of admission to the
    Law School but struck down an undergraduate admission policy based on a point system. It held
    that the Law School had a compelling interest in
    attaining a diverse student body and that its affirmative action policies were legally sound as evaluating each candidate as an individual.14 At the
    same time, the court invalidated the undergraduate
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    admission policy as not providing for individualized consideration of each candidate.15
    The ethical issues of beneficence and justice involved in these decisions also plague initiatives at
    the state level. In California, Proposition 209,
    passed in 1996, banned consideration of race, gender, or national origin in hiring and school admissions. In the state of Washington, Initiative 200
    adopted by the voters in 1998 eliminated all preferential treatment based on race or gender in government hiring and school admissions. In Florida, the
    Governor’s Cabinet enacted in 2000Rthe “One
    Florida” program that ended consideration
    I of race
    in university admissions and state contracts.16
    C
    These state actions have significant ethical effects
    on the health system and underserved A
    communities. They contribute to a shortage of physicians in
    R
    minority communities, and they deny many minorD 17
    ity candidates admission to medical school.
    Similar ethical public health dilemmas
    , are confronted with respect to health facilities. From a
    public health point of view, the need for equitable
    access to quality institutions and for fair
    A distribution of health care facilities takes priority over an
    D the prefindividual real estate developer’s ends or
    erences of for-profit hospital owners. R
    Offering a
    range of facilities to maximize choice suggests the
    I
    need for both public and private hospitals,
    community clinics and health centers, andEinpatient
    and outpatient mental health facilities, as well as
    N
    long-term care facilities and hospices. At the same
    time, not-for-profit providers, on several
    N performance variables, do a better job than the for-profit
    E
    institutions. Overall, studies since 1980 suggest
    that non profit providers out perform for profit
    providers on cost, quality, access, and
    1 charity
    care.18 For example, the medical loss ratio is much
    9 comhigher in nonprofit health care providers
    pared to for-profit health care providers.
    The
    0
    higher the medical loss ratio, the greater the proportion of revenue received that goes 2for health
    care rather than administration and management.
    T
    In 1995, for example, Kaiser Foundation Health
    Plan in California “devoted 96.8 percentSof its revenue to health care and retained only 3.2 percent
    325
    for administration and income.”19 They have lower
    disenrollment rates,20 offer more community benefits,21 feature more preventive services,22 too. How
    long this can continue to be the case in the highly
    competitive health care market is unknown because not-for-profits may have to adopt for-profit
    business practices to survive.23
    The financial crisis facing public hospitals
    throughout the nation poses an ethical problem of
    major proportions. At stake is the survival of facilities that handle an enormous volume of care for the
    poor, that train large numbers of physicians and
    other health personnel, and that make available
    specialized services—trauma care, burn units, and
    others—for the total urban and rural populations
    they serve.
    Research serves a public health purpose too. It
    has advanced medical technology, and its benefits
    in new and improved products should be accessible
    to all members of society. Public health ethics also
    focuses on the importance of research in assessing
    health system performance, including equity of access and medical outcomes. Only if what works
    and is medically effective can be distinguished from
    what does not work and what is medically ineffective, are public health interests best served. Health
    care resources need to be used wisely and not
    wasted. Health services research can help assure
    this goal. This is especially important in an era in
    which market competition appears, directly or indirectly, to be having a negative influence on research
    capacity.24
    Research is central to developing public health
    resources. Equity mandates a fair distribution of research resources among the various diseases that affect the public’s health because research is costly,
    resources are limited, and choices have to be made.
    Research needs both basic and applied orientation
    to assure quality. There is a need for research on
    matters that have been neglected in the past,25 as
    has been recognized in the field of women’s health.
    Correction of other gross inequities in allocating research funds is urgent. Recent reports indicate that
    younger scientists are not sufficiently consulted in
    the peer review process, and they do not receive
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    326
    their share of research funds. Ethical implications
    involving privacy, informed consent, and equity
    affect targeted research grants for AIDS, breast
    cancer, and other special diseases. The legal and
    ethical issues in the human genome project, and
    now stem cell research, involve matters of broad
    scope—wide use of genetic screening, information
    control, privacy, and possible manipulation of
    human characteristics—it is no surprise that Annas
    has called for “taking ethics seriously.”26
    Federal law in the United States governs conduct
    R
    of biomedical research involving human subjects.
    Ethical issues are handled by ethics advisory
    I
    boards, convened to advise the Department of
    C
    Health and Human Services on the ethics of
    biomedical or behavioral research projects, and A
    by
    institutional review boards of research institutions
    R
    seeking funding of research proposals. Both kinds
    D
    of board are charged with responsibility for reviewing clinical research proposals and for ensuring
    ,
    that the legal and ethical rights of human subjects
    are protected.27 Finding researchers to serve on
    IRBs is a growing problem because about half of A
    all
    researchers have serious conflicts of interest due to
    28
    the fact that they serve as industry consultants.D
    An overarching problem is the conflict of interest
    R
    of scientists who are judging the effectiveness of
    treatments and drugs and, at the same time, may Ibe
    employed by or serving as consultants to a pharmaE
    ceutical or biotechnology firm. In 2005, several sciN
    entists at the National Institutes of Health resigned
    in the wake of a new regulation banning NIH scienN
    tists from accepting funding from pharmaceutical
    E
    firms.29
    Among the principal concerns of these boards is
    assurance of fully informed and unencumbered
    1
    consent, by patients competent to give it, in order
    9
    to assure the autonomy of subjects. They are also
    concerned with protecting the privacy of human
    0
    subjects and the confidentiality of their relation to
    the project. An important legal and ethical duty2of
    researchers, in the event that a randomized clinical
    T
    trial proves beneficial to health, is to terminate the
    trial immediately and make the benefits availableS
    to
    the control group and to the treated group alike.
    PART FIVE Assessing and Regulating Health Services
    The ethical principles that should govern biomedical research involving human subjects are a
    high priority, but criticism has been leveled at the
    operation of some institutional review boards.
    Some say they lack objectivity and are overly identified with the interests of the researcher and the institution. Recommendations to correct this type of
    problem include appointing patient and consumer
    advocates to review boards, in addition to physicians and others affiliated with the institution and
    along with the sole lawyer who is generally a member of the review board; having consumer advocates involved early in drawing up protocols for the
    research; having third parties interview patients
    after they have given their consent to make sure
    that they understood the research and their choices;
    requiring the institution to include research in its
    quality assurance monitoring; and establishing a
    national human experimentation board to oversee
    the four thousand institutional review boards in the
    country.30 Others say the pendulum has moved in
    the other direction and that IRBs excessively limit
    researchers ability to do their studies and that they
    increase the cost of research, perhaps making it impossible to carry it out at all in some cases.
    Correction of fraud in science and the rights of
    subjects are important ethical considerations in developing knowledge. Ethical conflict between the
    role of the physician as caregiver and as researcher
    is not uncommon inasmuch as what is good for the
    research project is not always what is good for
    the patient. Certainly, in some instances society
    stands to benefit at the expense of the research subject, but respect for the basic worth of the individual means that he or she has a right to be informed
    before agreeing to participate in an experiment.
    Only when consent is informed, clear, and freely
    given can altruism, for the sake of advancing science and humanity, be authentic.
    Policy makers concerned with developing resources for health care thus confront tensions between protecting public health and protecting the
    rights of individual patients and providers. They
    face issues concerning allocation of scarce resources and use of expensive medical technology.
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    We trust that in resolving these issues their
    decisions are guided by principles of autonomy,
    beneficence, and justice as applied to the health of
    populations.
    ETHICAL ISSUES IN
    ECONOMIC SUPPORT
    R
    Nowhere is the public health ethical perspective
    clearer than on issues of economic support.
    PerI
    sonal autonomy and respect for privacy remain esC
    sential, as does beneficence. But a public health
    orientation suggests that the welfare A
    of society
    merits close regard for justice. It is imperative that
    R
    everyone in the population have equitable access
    to health care services with dignity, soDas not to
    discourage necessary utilization; in most
    , cases,
    this means universal health insurance coverage.
    Forty-five million Americans lack health insurance,
    which makes for poorer medical outcomes
    A even
    though individuals without health insurance do receive care in hospital emergency roomsDand community clinics. Most of the uninsured are
    R workers
    in small enterprises whose employers do not offer
    I
    31
    health insurance for their workers or dependents.
    The uninsured are predicted to rise to E
    56 million
    or 27.8% by 2013.32 The Institute of Medicine has
    N
    provided an up-to-date and thorough analysis of
    the scope of uninsurance and underinsurance
    in
    N
    America.33 The underinsured, those with coverage
    E
    that is not sufficient and leaves bills that the
    individual cannot pay, are also on the rise. This
    happens when employers shift health1insurance
    costs to employees with greater deductibles and
    9
    co-pays for example.34
    From a public health perspective, financial
    0 barriers to essential health care are inappropriate. Yet
    2 the fact
    they exist to a surprising degree. Witness
    that the cost reached $5,670 per personTin the US
    in 2003.35 If each and every human being is to deS fully
    velop to his or her full potential, to participate
    as a productive citizen in our democratic society,
    327
    then preventive health services and alleviation of
    pain and suffering due to health conditions that
    can be effectively treated must be available without
    financial barriers. Removing economic barriers to
    health services does not mean that the difference in
    health status between rich and poor will disappear.
    But it is a necessary, if not sufficient, condition for
    this goal.
    Economic disparity in society is a public health
    ethical issue related to justice. Increasing evidence
    suggests that inequality in terms of income differences between the rich and the poor has a large
    impact on a population’s health.36 This may be due
    to psychosocial factors,37 or a weakened societal
    social fabric,38 or loss of social capital,39 or a range
    of other factors.40 Whatever the cause, “income inequality, together with limited access to health care,
    has serious consequences for the working poor.”41
    From a public health point of view, the economic resources to support health services should
    be fair and equitable. Any individual’s contribution
    should be progressive, based on ability to pay. This
    is especially important because the rise of managed
    care has made it increasingly difficult to provide
    charity care.42 This may be because of funding restrictions for a defined population. Although some
    individual contribution is appropriate—no matter
    how small—as a gesture of commitment to the
    larger community, it is also ethically befitting for
    the nation to take responsibility for a portion of
    the cost. The exact proportion may vary across
    nation and time, depending on the country’s
    wealth and the public priority attributed to health
    services.43
    Similarly, justice and equity suggest the importance of the ethical principle of social solidarity in
    any number of forms.44 By definition, social insurance means that there is wisdom in assigning responsibility for payment by those who are young
    and working to support the health care of children
    and older people no longer completely independent. A public health orientation suggests that social solidarity forward and backward in time, across
    generations, is ethically persuasive. Those in the
    most productive stages of the life cycle today were
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    328
    once dependent children, and they are likely one
    day to be dependent older persons.
    Institutions such as Social Security and Medicare
    play a moral role in a democracy. They were established to attain common aims and are fair in that
    they follow agreed-upon rules.45 Proposals to privatize them undermine these goals. Financing of the
    Social Security system in part by individual investment accounts, favored by the Bush Administration, carries serious risks in case of market failure
    and certainly does not assure the subsidy for lowR
    income workers contained in the current government system. With respect to Medicare, the Bush
    I
    Administration’s support of a voucher system enC
    abling the beneficiary to buy private insurance will
    induce healthy and affluent elderly to opt out A
    of
    Medicare, leaving Medicare as a welfare program
    R
    for the sick and the poor. With less income, MediD
    care will be forced to cut services.
    Social solidarity between the young and the ,elderly are critical. As members of a society made up
    of overlapping communities, our lives are intricately
    linked together. No man or woman is an island; not
    A
    even the wealthiest or most “independent” can exist
    D
    alone. The social pact that binds us to live in peace
    together requires cooperation of such a fundamenR
    tal nature that we could not travel by car (assuming
    respect for traffic signals) to the grocery store Ito
    purchase food (or assume it is safe for consumpE
    tion) without appealing to social solidarity. These
    N
    lessons apply to health care as well.
    In 1983, the President’s Commission for the
    N
    Study of Ethical Problems in Medicine and BiomedE
    ical and Behavioral Research made as its first and
    principal recommendation on ethics in medicine
    that society has an obligation to assure equitable
    1
    access to health care for all its citizens.46 Equitable
    9
    access, the commission said, requires that all citizens be able to secure an adequate level of care
    0
    without excessive burden. Implementation of this
    principle as an ethical imperative is even more 2
    urgent all these years later, as an increasing number
    T
    of people become uninsured and as the prices of
    S
    pharmaceuticals dramatically increase.47
    PART FIVE Assessing and Regulating Health Services
    ETHICAL ISSUES IN
    ORGANIZATION OF
    SERVICES
    The principal ethical imperative in organization of
    health services is that services be organized and distributed in accordance with health needs and the
    ability to benefit. The problem with rationing on
    the basis of ability to pay is that it encourages the
    opposite.48 The issues of geographic and cultural
    access also illustrate this ethical principle.
    To be fair and just, a health system must minimize geographic inequity in distributing care. Rural
    areas are underserved, as are inner cities. Any number of solutions have been proposed and tried to
    bring better access in health services to underserved
    areas. They include mandating a period of service
    for medical graduates as a condition of licensure,
    loan forgiveness and expansion of the National
    Health Service Corps, rural preceptorships, creating economic incentives for establishing a practice
    in a rural area, and employing physician assistants
    and nurse practitioners.49 Telemedicine may make
    the best medical consultants available to rural areas
    in the near future,50 but the technology involves
    initial start-up costs that are not trivial. Higher
    Medicare payments to rural hospitals also ensure
    that they will remain open.51
    Similarly, the principles of autonomy and beneficence require health services to be culturally relevant to the populations they are designed to
    serve.52 This means that medical care professionals need to be able to communicate in the language of those they serve and to understand the
    cultural preferences of those for whom they seek
    to provide care.53 The probability of success is enhanced if needed health professionals are from the
    same cultural background as those they serve. This
    suggests that schools of medicine, nursing, dentistry, and public health should intensify their
    efforts to reach out and extend educational and
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    training opportunities to qualified and interested
    members of such populations. To carry out such
    programs, however, these schools must have the
    economic resources required to offer fellowships
    and teaching assistant positions.
    The development of various forms of managed
    care—health maintenance organizations, prepaid
    group practices, preferred provider organizations,
    and independent practice associations—raise another set of ethical questions. As experienced in
    the United States in recent years, managed care is
    designed more to minimize costs thanRto ensure
    that health care is efficient and effective.
    I If managed care ends up constraining costs by depriving
    C
    individuals of needed medical attention (reducing
    A for inmedically appropriate access to specialists,
    stance), then it violates the ethical principle of
    R
    beneficence because such management interferes
    with doing good for the patient.54 IfDmanaged
    care is employed as a cost-containment
    , scheme
    for Medicaid and Medicare without regard to
    quality of care, it risks increasing inequity. It
    could even contribute to a two-tiered health
    A care
    system in which those who can avoid various
    D
    forms of managed care by paying privately
    for
    their personal health services will obtain
    higherR
    quality care.
    I
    Historically, the advantages of staff-model
    managed care are clear: team practice, emphasis
    E on primary care, generous use of diagnostic and theraN
    peutic outpatient services, and prudent use of
    hospitalization. All contribute to cost
    N containment. At the same time, managed care systems
    E
    have the disadvantage of restricted choice of
    provider. Today’s for-profit managed care companies run the risk of under-serving; 1they may
    achieve cost containment through cost shifting
    9
    and risk selection.55
    The ethical issues in the relationships
    0 among
    physicians, patients, and managed care organizations include denial of care, restricted 2referral to
    specialists, and gag rules that bar physicians
    T from
    telling patients about alternative treatments
    S or from
    (which may not be covered by the plan)
    329
    discussing financial arrangements between the
    physician and the plan (which may include incentives for cost containment).56 Requiring public disclosure of information about these matters has
    been proposed as a solution, but there is little evidence that disclosure helps the poor and illiterate
    choose a better health plan or a less-conflicted
    health care provider.
    The ethical issues in managed care are illustrated most sharply by the question of who decides
    what is medically necessary: the physician or others, the disease management program, the insurer,
    the employer, or the state legislature.57 This question is not unique to managed care; it has also
    arisen with respect to insurance companies and
    Medicaid.58 On the one hand, the physician has a
    legal and ethical duty to provide the standard of
    care that a reasonable physician in the same or
    similar circumstances would. On the other hand,
    insurers have traditionally specified what is covered or not covered as medically necessary in insurance contracts. The courts have sometimes reached
    different results, depending on the facts of the case,
    the character of the treatment sought (whether generally accepted or experimental), and the interpretation of medical necessity. With the rise of managed care, the problem becomes even more of an
    ethical dilemma because, as even those highly favorable to managed care agree, there is a risk of
    too little health care.59
    Malpractice suits against managed care organizations in self-insured plans are barred by the provision in the Employee Retirement Income Security
    Act that preempts or supersedes “state laws that
    contain provisions involving any type of employee
    benefit plan.” As a result of the preemption, employees covered by such plans are limited to the relief provided by ERISA—only the cost of medical
    care denied—with no compensation for lost wages
    and pain and suffering. Self-insured health insurance plans that cause injury by denying care or providing substandard care have immunity from suit
    in state courts because of legal interpretation of
    ERISA by the US Supreme Court. In view of the
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    330
    fact that 140 million people receive their health
    care through plans sponsored by employers and
    covered by ERISA, it is a serious matter of equity to
    bar them from access to the state courts for medical
    malpractice.60
    In June of 2004, the Supreme Court “immunized
    employer-sponsored health plans against damage
    suits for wrongful denial of coverage.” It thus voided
    laws that allowed such suits in 10 states. This will
    mean that the legal risk to health plans for denying
    coverage will be reduced. The poor will be the greatR
    est losers as they cannot afford to fight such denials
    through the now available reviews mandated in I40
    of the states. This law is also likely to make for high
    C
    malpractice claims as physicians and hospital do
    61
    A
    not have legal shelter from responsibility.
    As more and more integrated health care delivR
    ery systems are formed, as more mergers of manD
    aged care organizations occur, as pressure for cost
    containment increases, ethical issues concerning
    ,
    conflict of interest, quality of care choices, and patients’ rights attain increasing importance. The
    principles of autonomy, beneficence, and justice are
    A
    severely tested in resolving the ethical problems facD
    ing a complex, corporate health care system.

    If medicine is for-profit,” as seems to be the case
    R
    today and for the near future in the United States,
    I
    then the ethical dilemma between patients’ inter62
    ests and profits will be a continuing problem.E
    Sometimes the two can both be served, but it is unN
    likely to be the case in all instances. Surveys of business “executives admit and point out the presence
    N
    of numerous generally accepted practices in their
    E
    industry which they consider unethical.”63 As
    Fisher and Welch conclude, “Stakeholders in the increasingly market-driven U.S. health care system
    1
    have few incentives to explore the harms of the
    technologies from which they stand to profit.”964
    That both consumers and employers are concerned
    0
    about quality of care is clear from Paul Ellwood’s
    2
    statement expressing disappointment in the evolution of HMOs because “they tend to place too
    T
    much emphasis on saving money and not enough
    S
    on improving quality—and we now have the tech65
    nical skill to do that.”
    PART FIVE Assessing and Regulating Health Services
    ETHICAL ISSUES IN
    MANAGEMENT OF
    HEALTH SERVICES
    Management involves planning, administration, regulation, and legislation. The style of management
    depends on the values and norms of the population.
    Planning involves determining the population’s
    health needs (with surveys and research, for example) and then ensuring that programs are in place to
    provide these services. A public health perspective
    suggests that planning is appropriate to the extent
    that it provides efficient, appropriate health care
    (beneficence) to all who seek it (equity and justice).
    Planning may avoid waste and contribute to rational
    use of health services. But it is also important that
    planning not be so invasive as to be coercive and
    deny the individual any say in his or her health care
    unless such intervention is necessary to protect public health interests. The ethical principle of autonomy preserves the right of the individual to refuse
    care, to determine his or her own destiny, especially
    when the welfare of others is not involved. A balance
    between individual autonomy and public health intervention that affords benefit to the society is not
    easy to achieve. But in some cases the resolution of
    such a dilemma is clear, as in the case for mandatory
    immunization programs. Equity and beneficence demand that the social burdens and benefits of living
    in a disease-free environment be shared. Therefore,
    for example, immunization requirements should
    cover all those potentially affected.
    Health administration has ethical consequences
    that may be overlooked because they appear ethically neutral: organization, staffing, budgeting, supervision, consultation, procurement, logistics,
    records and reporting, coordination, and evaluation.66 But all these activities involve ethical
    choices. Faced with a profit squeeze, the managed
    care industry is pressuring providers to reduce costs
    and services.67 The result has been downsizing,
    which means more unlicensed personnel are hired
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    to substitute for nurses.68 California is the first state
    to mandate nurse-to-patient staffing ratios.69 Surveys of doctors suggest patients do not always get
    needed care from HMOs.70 Denial of appropriate
    needed health care is an ethical problem related to
    beneficence. In addition, the importance of privacy
    in record keeping (to take an example) raises once
    again the necessity to balance the ethical principles
    of autonomy and individual rights with social justice and the protection of society.71
    Distribution of scarce health resources is anR
    other subject of debate. The principle of first come,
    first served may initially seem equitable.IBut it also
    incorporates the “rule of rescue,” whereby
    C a few
    lives are saved at great cost, and this policy results
    AThe costin the “invisible” loss of many more lives.
    benefit or cost-effectiveness analysis of health
    R economics attempts to apply hard data to administrative decisions. This approach, however,Ddoes not
    escape ethical dilemmas because the act, of assigning numbers to years of life, for example, is itself
    value-laden. If administrative allocation is determined on the basis of the number of years
    A of life
    saved, then the younger are favored over the older,
    D factors
    which may or may not be equitable. If one
    into such an analysis the idea of “quality”
    R years of
    life, other normative assumptions must be made as
    I
    to how important quality is and what constitutes
    E assign a
    quality. Some efforts have been made to
    dollar value to a year of life as a tool for administerN
    ing health resources. But here, too, we encounter
    worrisome normative problems. DoesNability to
    pay deform such calculations?72
    E
    Crucial to management of health services are
    legal tools—legislation, regulations, and sometimes
    litigation—necessary for fair administration
    1 of programs. Legislation and regulations are essential for
    9 serve to
    authorizing health programs; they also
    remedy inequities and to introduce innovations
    in a
    0
    health service system. Effective legislation depends
    2
    on a sound scientific base, and ethical questions
    are
    especially troubling when the scientific T
    evidence is
    uncertain.
    S
    For example, in a landmark decision in 1976,
    the Court of Appeals for the District of Columbia
    331
    upheld a regulation of the Environmental Protection Agency restricting the amount of lead additives
    in gasoline based largely on epidemiological evidence.73 Analysis of this case and of the scope of
    judicial review of the regulatory action of an agency
    charged by Congress with regulating substances
    harmful to health underlines the dilemma the court
    faced: the need of judges trained in the law, not in
    science, to evaluate the scientific and epidemiological evidence on which the regulatory agency based
    its ruling.74 The majority of the court based its upholding of the agency’s decision on its own review
    of the evidence. By contrast, Judge David Bazelon
    urged an alternative approach: “In cases of great
    technological complexity, the best way for courts to
    guard against unreasonable or erroneous administrative decisions is not for the judges themselves to
    scrutinize the technical merits of each decision.
    Rather, it is to establish a decision making process
    that assures a reasoned decision that can be held
    up to the scrutiny of the scientific community and
    the public.”75
    The dilemma of conflicting scientific evidence is
    a persistent ethical minefield, as reflected by a 1993
    decision of the U.S. Supreme Court involving the
    question of how widely accepted a scientific process or theory must be before it qualifies as admissible evidence in a lawsuit. The case involved the
    issue of whether a drug prescribed for nausea during pregnancy, Bendectin, causes birth defects. Rejecting the test of “general acceptance” of scientific
    evidence as the absolute prerequisite for admissibility, as applied in the past, the Court ruled that trial
    judges serve as gatekeepers to ensure that pertinent
    scientific evidence is not only relevant but reliable.
    The Court also suggested various factors that might
    bear on such determinations.76
    It is significant for the determination of ethical
    issues in cases where the scientific evidence is uncertain that epidemiological evidence, which is the
    core of public health, is increasingly recognized as
    helpful in legal suits.77 Of course, it should be
    noted that a court’s refusal (or an agency’s) to act
    because of uncertain scientific evidence is in itself a
    decision with ethical implications.
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    PART FIVE Assessing and Regulating Health Services
    332
    Enactment of legislation and issuance of regulations are important for management of a just health
    care system, but these strategies are useless if they
    are not enforced. For example, state legislation has
    long banned the sale of cigarettes to minors, but
    only recently have efforts been made to enforce
    these statutes rigorously through publicity, “stings”
    (arranged purchases by minors), and penalties on
    sellers, threats of license revocation, denial of federal
    funds under the Synar Amendment, and banning
    cigarette sales from vending machines.78 A novel
    R
    case of enforcement involves a Baltimore ordinance
    prohibiting billboards promoting cigarettes in areas
    I
    where children live, recreate, and go to school, enC
    acted in order to enforce the minors’ access law
    A
    banning tobacco sales to minors. The Baltimore
    ordinance has not been overturned despite the fact
    R
    that a Massachusetts regulation restricting advertisD
    ing of tobacco and alcohol near schools was struck
    down as unconstitutional by the US Supreme Court
    ,
    on the ground of preemption.79
    Thus, management of health services involves
    issues of allocating scarce resources, evaluating
    A
    scientific evidence, measuring quality of life, and
    D
    imposing mandates by legislation and regulations.
    Although a seemingly neutral function, manageR
    ment of health services must rely on principles of
    I
    autonomy, beneficence, and justice in its decisionmaking process.
    E
    ETHICAL ISSUES IN
    DELIVERY OF CARE
    N
    N
    E
    1
    Delivery of health services—actual provision of
    9
    health care services—is the end point of all the
    other dimensions just discussed. The ethical consid0
    erations of only a few of the many issues pertinent
    2
    to delivery of care are explored here.
    Resource allocation in a time of cost containT
    ment inevitably involves rationing. At first blush, raS
    tioning by ability to pay may appear natural, neutral, and inevitable, but the ethical dimensions for
    delivery of care may be overlooked. If ability to pay
    is recognized as a form of rationing, the question of
    its justice is immediately apparent. The Oregon
    Medicaid program (Oregon Health Plan) is another
    example. It is equitable by design and grounded in
    good part in the efficacy of the medical procedure
    in question, thus respecting the principle of ethical
    beneficence. It is structured to extend benefits to a
    wider population of poor people than those entitled to care under Medicaid. It has been tested for
    more than 10 years in its effort to provide a basic
    level of care deemed effective and appropriate without over-treatment. The Prioritized List of Health
    Services continues to be re-evaluated and updated
    in light of new evidence by the Health Services
    Commission of the Department of Administrative
    Services’ Office for Oregon Health Policy and Research. The Legislature continues to set the funding
    level to cover the services on the prioritized list
    without having re-arranged them.80
    The plan does not qualify as equitable and fair,
    however, because it does not apply to the whole
    population of Oregon, but only to those on Medicaid. It denies some services to some persons on
    Medicaid in order to widen the pool of beneficiaries. It has, therefore, not resolved all the ethical
    problems in this respect.81
    Rationing medical care is not always ethically
    dubious; rather, it may conform to a public health
    ethic. In some cases, too much medical care is
    counterproductive and may produce more harm
    than good. Canada, Sweden, the United Kingdom,
    and the state of Oregon, among others, have rationing of one sort or another.82 For example,
    Canada rations health care, pays one-third less per
    person than the United States, and offers universal
    coverage; yet health status indicators do not suggest that Canadians suffer. In fact, on several performance indicators Canada surpasses the United
    States.83 If there were better information about
    medical outcomes and the efficacy of many medical procedures, rationing would actually benefit
    patients if it discouraged the unneeded and inappropriate treatment that plagues the U.S. health
    system.84
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    Rationing organ transplants, similarly, is a matter of significant ethical debate because fewer organs are available for transplant than needed for
    the 85,000 people on waiting lists. Rationing,
    therefore, must be used to determine who is given a
    transplant. Employing tissue match makes medical
    sense and also seems ethically acceptable. But to
    the extent that ability to pay is a criterion, ethical
    conflict is inevitable. It may, in fact, go against scientific opinion and public health ethics if someone
    who can pay receives a transplant even though the
    R for a patissue match is not so good as it would be
    tient who is also in need of a transplant Ibut unable
    to pay the cost. Rationing on this basis seems ethiC
    cally unfair and medically ill advised. It is no surA Act,
    prise, then, that the National Organ Transplant
    adopted in 1984, made it illegal to offer or receive
    R
    payment for organ transplantation. Yet the sale of
    organs for transplantation still exists. ItDhas even
    been advocated as a market-friendly, for-profit
    solu,
    tion to the current supply problems.85
    One solution would be to make more organs
    available through mandatory donation A
    from fatal
    automobile accidents, without explicit consent of
    D societies
    individuals and families. A number of
    have adopted this policy of presumed consent
    beR
    cause the public health interest of society and the
    seriousness of the consequences are soI great for
    those in need of a transplant that it is possible
    to
    E
    justify ignoring the individual autonomy (preferN
    ences) of the accident victim’s friends and relatives.
    Spain leads other nations regarding organ
    N donation with 33.8 donors pmp in 2003 by interpreting
    E
    an absence of prohibition to constitute a near-death
    patient’s implicit authorization for organ transplantation.86 This has not been the case in 1
    the United
    States to date.87
    9
    Delivery of services raises conflict-of-interest
    questions for providers that are of 0
    substantial
    public health importance. Criminal prosecution of
    2 threefold
    fraud in the health care sector increased
    88
    between 1993 and 1997. In today’s
    T marketdriven health system, about half of all doctors reS of a
    port that they have “exaggerated the severity
    patient’s condition to get them care they think is
    333
    medically necessary.”89 Hospitals pressed by competitive forces strain to survive and in some cases
    do so only by less-than-honest cost shifting—
    and even direct fraud. A recent survey of hospital
    bills found that more than 99 percent included
    “mistakes” that favored the hospital.90
    Class action suits claim that HMOs are guilty of
    deceiving patients because they refuse to reveal financial incentives in physician payment structures.91 Physicians have been found to refer patients
    to laboratories and medical testing facilities that
    they co-own to a far greater extent than can be medically justified.92 As the trend to make medicine a
    business develops, the AMA’s Council on Ethical
    and Judicial Affairs has adopted guidelines for the
    sale of nonprescription, health-related products in
    physicians’ offices, but problems remain.93 The purpose is to “help protect patients and maintain physicians’ professionalism.”94 The public health ethic of
    beneficence is called into question by unnecessary
    products and inappropriate medical tests.
    The practice of medicine and public health
    screening presents serious ethical dilemmas. Screening for diseases for which there is no treatment, except where such information can be used to postpone onset or prevent widespread population
    infection, is difficult to justify unless the information is explicitly desired by the patient for personal
    reasons (life planning and reproduction). In a similar case, screening without provision to treat those
    discovered to be in need of treatment is unethical.
    Public health providers need to be sure in advance
    that they can offer the health services required to
    provide care for those found to be affected. These
    are the ethical principles of beneficence and social
    justice.
    The tragic epidemic of HIV/AIDS has raised serious ethical questions concerning testing, reporting, and partner notification. The great weight of
    authority favors voluntary and confidential testing,
    so as to encourage people to come forward for testing, counseling, and behavior change. A study by
    the U.S. Centers for Disease Control and Prevention (CDC) concludes that confidential namesbased reporting of HIV has not deterred testing
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    334
    and treatment.95 Nevertheless, concern about violation of privacy and possible deterrence of testing
    and treatment with confidential names-based reporting of HIV persists.
    This issue raises sharply the ethical conflict between the individual’s right to confidentiality and
    the needs of public health. Some guidance for resolving ethical questions in this difficult sphere is
    presented by Stephen Joseph, former commissioner
    of health for New York City, who states that the
    AIDS epidemic is a public health emergency involvR
    ing extraordinary civil liberties issues—not a civil
    I
    liberties emergency involving extraordinary public
    health issues.96
    C
    Partner notification was at first generally disapA
    proved on grounds of nonfeasibility and protection
    of privacy, but in accordance with CDC guidelines,
    R
    some states have enacted legislation permitting a
    physician or public health department to notifyDa
    partner that a patient is HIV-positive if the physi,
    cian believes that the patient will not inform the
    partner.97
    With the finding that administration of AZT durA
    ing pregnancy to an HIV-positive woman reduces
    D
    the risk of transmission of the virus to the infant
    dramatically, CDC recommends that all pregnant
    R
    women be offered HIV testing as early in pregI
    nancy as possible because of the available treatE
    ments for reducing the likelihood of perinatal transmission and maintaining the health of the woman.
    N
    CDC also recommends that women should be
    N
    counseled about their options regarding pregnancy
    by a method similar to genetic counseling.98
    E
    The field of reproductive health is a major public
    health concern, affecting women in their reproductive years. Here the principles of autonomy, benefi1
    cence, and justice apply to providing contraceptive
    9
    services, including long-acting means of contraception, surgical abortion, medical abortion made pos0
    sible by development of Mifepristone, sterilization,
    2
    and use of noncoital technologies for reproduction.
    The debate on these issues has been wide, abrasive,
    T
    and divisive. Thirty-two years after abortion was
    S
    legalized by the U.S. Supreme Court’s decision in
    Roe v. Wade,99 protests against abortion clinics
    PART FIVE Assessing and Regulating Health Services
    have escalated. Violence against clinics and murders of abortion providers threaten access to abortion services and put the legal right to choose to terminate an unwanted pregnancy in jeopardy. The
    shortage of abortion providers in some states and
    in many rural areas restricts reproductive health services. The mergers of Catholic hospitals with secular institutions and the insistence that the merged
    hospital be governed by the Ethical and Religious
    Directives for Catholic Health Care Services means
    that not only abortion services are eliminated but
    also other contraceptive and counseling services
    (except for “natural family planning”), sterilization
    procedures, infertility treatments, and emergency
    postcoital contraception (even for rape victims).100
    The Food and Drug Administration’s refusal to approve over-the-counter sales of emergency contraception, despite the approval of two scientific committees, is a particularly troubling ethical decision.
    We state our position as strongly favoring the
    pro-choice point of view in order to ensure autonomy of women, beneficence for women and their
    families faced with unwanted pregnancy, and justice in society. In the highly charged debate on
    teenage pregnancy, we believe that social realities,
    the well-being of young women and their children,
    and the welfare of society mandate access to contraception and abortion and respect for the autonomy of young people. The ethics of parental consent and notification laws, which often stand as a
    barrier to abortions needed and wanted by adolescents, is highly questionable. Economists estimate
    the cost of such laws to be around $150 million in
    Texas alone.101
    Many other important ethical issues in delivering
    health care have not been discussed extensively in
    this chapter because of space limitations. There are
    three such issues that we want to mention briefly.
    First, the end-of-life debate is generally considered a matter of medical ethics involving the patient, his or her family, and the physician. But this
    issue is also a matter of public health ethics because
    services at the end of life entail administrative and
    financial dimensions that are part of public health
    and management of health services.The Terri Shiavo
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    Case is an example where the potential alternative
    use of societal resources brings to mind the contradictions involved in end-of-life issues.102
    Second, in the field of mental health, the conflict between the health needs and legal rights of
    patients on the one hand and the need for protection of society on the other illustrates sharply the
    ethical problems facing providers of mental health
    services. This conflict has been addressed most
    prominently by reform of state mental hospital admission laws to make involuntary admission to a
    R with immental hospital initially a medical matter,
    mediate and periodic judicial review as Ito the propriety of hospitalization-review in which a patient
    C
    advocate participates.103 The Tarasoff case presents
    another problem in providing mental A
    health services: the duty of a psychiatrist or psychologist to
    R
    warn an identified person of a patient’s intent to
    D
    kill the person, despite the rule of confidentiality
    104
    In
    governing medical and psychiatric practice.
    ,
    both instances, a public health perspective favors
    protection of society as against the legal rights of
    individuals.
    A
    Third, basic to public health strategies and effecD
    tive delivery of preventive and curative services
    are
    records and statistics. The moral and legal
    imperaR
    tive of privacy to protect an individual’s medical
    I requiring
    record gives way to public health statutes
    reporting of gunshot wounds, communicable
    disE
    eases, child abuse, and AIDS.105 More generally,
    N
    the right of persons to keep their medical records
    confidential conflicts with society’s need
    N for epidemiological information to monitor the incidence
    E
    and prevalence of diseases in the community and to
    determine responses to this information. At the
    same time, it is essential, for example, that
    1 an individual’s medical records be protected from abuse
    9 resoluby employers, marketers, etc.106 A common
    tion of this problem is to make statistics
    0 available
    without identifying information.
    Congress has adopted HIPAA (Health2Insurance
    Portability and Accountability Act) in 1996
    T to protect the privacy of medical records. Only in 2003
    S
    did these aspects of the law take effect, HIPAA
    limits who may see medical records, how the records
    335
    are stored, and even how they are disposed of when
    no longer needed. Compliance costs have been
    enormous.107
    ETHICAL ISSUES IN
    ASSURING QUALITY
    OF CARE
    If a public health ethic requires fair and equitable
    distribution of medical care, then it is essential that
    waste and inefficiency be eliminated. Spending
    scarce resources on useless medical acts is a violation of a public health ethic.108 To reach this public
    health goal, knowledge about what is useful and
    medically efficacious is essential.
    As strategies for evaluating the quality of health
    care have become increasingly important, the ethical dimensions of peer review, practice guidelines,
    report cards, and malpractice suits—all methods of
    quality assurance—have come to the fore. Established in 1972 to monitor hospital services under
    Medicare to ensure that they were “medically necessary” and delivered in the most efficient manner,
    professional standards review organizations came
    under attack as over-regulatory and too restrictive.109 Congress ignored the criticism and in 1982
    passed the Peer Review Improvement Act, which
    did not abolish outside review but consolidated the
    local peer review agencies, replaced them with
    statewide bodies, and increased their responsibility.110 In 1986, Congress passed the Health Care
    Quality Improvement Act, which established national standards for peer review at the state and
    hospital levels for all practitioners regardless of
    source of payment.111 The act also established a national data bank on the qualifications of physicians
    and provided immunity from suit for reviewing
    physicians acting in good faith.
    The functions of peer review organizations
    (PROs) in reviewing the adequacy and quality of care
    necessarily involve some invasion of the patient’s privacy and the physician’s confidential relationship
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    336
    with his or her patient. Yet beneficence and justice
    in an ethical system of medical care mandate a
    process that controls the cost and quality of care.
    Finding an accommodation between protection of
    privacy and confidentiality on the one hand and
    necessary but limited disclosure on the other has
    furthered the work of PROs. Physicians whose
    work is being reviewed are afforded the right to a
    hearing at which the patient is not present, and patients are afforded the protection of outside review
    in accordance with national standards.
    Practice guidelines developed by professional R
    associations, health maintenance organizations and
    I
    other organized providers, third-party payers, and
    C
    governmental agencies are designed to evaluate the
    A
    appropriateness of procedures. Three states—
    Maine, Minnesota, and Vermont—have passed legR
    islation permitting practice guidelines to be used as
    D
    a defense in malpractice actions under certain circumstances.112 Defense lawyers are reluctant to use
    ,
    this legislation, however, because they fear their
    case will be caught up in a lengthy constitutional
    appeal. Such a simplistic solution, however, avoids
    A
    the question of fairness: whose guidelines should
    prevail in the face of multiple sets of guidelines D
    issued by different bodies, and how should accomR
    modation be made to evolving and changing stanI
    dards of practice?113
    Beneficence and justice are involved in full disE
    closure of information about quality to patients.
    N
    Health plan report cards aim to fulfill this role.114
    Employers, too, could use report cards to choose
    N
    health plans for their employees, though some
    E
    studies suggest that many employers are interested
    115
    far more in cost than quality.
    How well reports
    actually measure quality is itself subject to de1
    bate.116 These are discussed in Part 3 of this book.
    9
    Malpractice suits constitute one method of regulating the quality of care, although an erratic and
    0
    expensive system. The subject is fully discussed else2
    where in this volume. Here we raise only the ethical
    issue of the right of the injured patient to compenT
    sation for the injury and the need of society for a
    S
    system of compensation that is more equitable and
    more efficient than the current system.
    PART FIVE Assessing and Regulating Health Services
    The various mechanisms for ensuring quality of
    care all pose ethical issues. Peer review requires
    some invasion of privacy and confidentiality to conduct surveillance of quality, although safeguards
    have been devised. Practice guidelines involve some
    interference with physician autonomy but in return
    afford protection for both the patient and the
    provider. Malpractice suits raise questions of equity, since many injured patients are not compensated. In the process of developing and improving
    strategies for quality control, the public health perspective justifies social intervention to protect the
    population.
    MECHANISMS FOR
    RESOLVING ETHICAL
    ISSUES IN HEALTH CARE
    Even in the absence of agreement on ethical assumptions, and in the face of diversity and complexity that prohibit easy compromise, mechanisms
    for resolving ethical dilemmas in public health do
    exist. Among these are ombudsmen, institutional
    review boards, ethics committees, standards set by
    professional associations, practice guidelines, financing mechanisms, and courts of law. Some of
    these mechanisms are voluntary. Others are legal.
    None is perfect. Some, such as financing mechanisms, are particularly worrisome.
    Although ethics deals with values and morals,
    the law has been very much intertwined with ethical issues. In fact, the more that statutes, regulations, and court cases decide ethical issues, the narrower is the scope of ethical decision making by
    providers of health care.117 For example, the conditions for terminating life support for persons in a
    persistent vegetative state are clearer, when the
    patient has an up-to-date living will. The scope of
    decision making by physicians and families is constrained. A court of law, therefore, is an important
    mechanism for resolving ethical issues in such
    cases.
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    CHAPTER 15 Ethical Issues in Public Health and Health Services
    The law deals with many substantive issues in
    numerous fields, including that of health care. It
    also has made important procedural contributions
    to resolving disputes by authorizing, establishing,
    and monitoring mechanisms or processes for handling claims and disputes. Such mechanisms are
    particularly useful for resolving ethical issues in
    health care because they are generally informal and
    flexible and often involve the participation of all
    the parties. Administrative mechanisms are much
    less expensive than litigation and in this respect poR
    tentially more equitable.
    Ombudsmen in health care institutions
    I are a
    means of providing patient representation and adC
    vocacy. They may serve as channels for expression
    A families.
    of ethical concerns of patients and their
    Ethics committees in hospitals and managed
    R
    care organizations operate to resolve ethical issues
    involving specific cases in the institution.DThey may
    be composed solely of the institution’s staff,
    , or they
    may include an ethicist specialized in handling
    such problems.
    Institutional review boards, discussedA
    earlier, are
    required to evaluate research proposals for their sciD
    entific and ethical integrity.
    Practice guidelines, also discussed earlier,
    R offer
    standards for ethical conduct and encourage professional behavior that conforms to Iprocedural
    norms generally recognized by experts in
    Ethe field.
    Finally, financing mechanisms that create incenN
    tives for certain procedures and practices have the
    economic power to encourage ethical conduct.
    PerN
    haps the highest ethical priority in health care in
    E
    the United States is the achievement of universal
    coverage of the population by health insurance. At
    the same time, financing mechanisms may
    1 function
    to encourage the opposite behavior.118
    As the health care system continues to9deal with
    budget cuts, greater numbers of uninsured
    0 persons,
    and restructuring into managed care and integrated
    delivery systems, ethical questions loom2large, Perhaps their impact can be softened by imaginative
    T
    and rational strategies to finance, organize, and deS prinliver health care in accordance with the ethical
    ciples of autonomy, beneficence, and justice.
    337
    Ethical issues in public health and health services management are likely to become increasingly
    complex in the future. New technology and advances in medical knowledge challenge us and raise
    ethical dilemmas. In the future they will need to be
    evaluated and applied in a public health context
    and submitted to a public health ethical analysis.
    Few of these developments are likely to be entirely
    new and without precedent, however. Already, current discussions, such as that presented here, may
    inform these new developments.
    ENDNOTES
    1
    2
    3
    4
    5
    6
    Beauchamp, T. L., & Childress, J. F. (1989).
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    Burris, S. (1997). The Invisibility of Public Health:
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    Annas, G. J. (2004). American Bioethics: Crossing
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    Another public health question is how threats to
    the environment should be reconciled with the
    need for employment. We acknowledge that issues
    in environmental control have an enormous impact
    on public health. Here; however, our focus is on
    the ethical issues in policy and management of
    personal health services. For a discussion of equity
    and environmental matters, see Paehlke, R., &
    Vaillancourt, R. P. (1993). Environment/Equality:
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    This outline is taken from Roemer, M. I. National
    Health Systems of the World, Vol. 1: The Countries.
    (New York: Oxford University Press, 1991).
    Financial resources are treated later in the section
    on economic support.
    Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part.
    PART FIVE Assessing and Regulating Health Services
    338
    7
    8
    9
    10
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    12
    13
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    15
    16
    17
    18
    For an example of the symbiotic relationship
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    PART FIVE Assessing and Regulating Health Services
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    PART FIVE Assessing and Regulating Health Services
    344
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