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)

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
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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.
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PART FIVE Assessing and Regulating Health Services
338
7
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PART FIVE Assessing and Regulating Health Services
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Grading May Be Too Easy on Health …