Healthcare Administration

Healthcare Administration

Instructions: This assignment must be done in APA format. A minimum word count of 1600 for the overall

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assignment (without references included) is required. A minimum of four (4) scholarly references along with in-text citations is also required for this assignment. However, each question ask for different things so please pay attention. Also, although this assignment is in APA format; please keep the question and answer line up (see example below) For Example: Question: XYZ Answer: XYZ Reference: XYZ Note: Please FOLLOW instructions and keep the above format. Each question is separate. DO NOT COMBINE. 1. Knowledge: What are the two key differences between medical / personal ethics and public health ethics? 2. 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? 3. 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. 4. 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 5. 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? 6. 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? Instructors Note: Each of these needn’t be long or expansive. Brevity is the soul of wit (Shakespeare). Practice efficiency and directness in your answers. Get to the point quickly. Avoid unnecessary “backfill”. Every word needs to make a contribution to the end points that you intend to make. Part Two Write a 150 word response to each discussion post. A minimum of two references per post is required. In-text citations must be included and cited properly. Note: Write the response as if you are talking to a person in person. Post One Knowledge Public health ethics and medical ethics have similar principles, but in different aspects. Public health ethics includes autonomy, right of privacy and freedom of action in society (Williams & Torrens, 2008). Medical ethics on the other hand focuses on an individual’s privacy, individual liberty, freedom of choice and selfcontrol of the individual in a medical setting. Medical ethics is the main driver of informed consent. Public health ethics put a strong emphasis on the community and the duty to take action in the name of the population well-being, which is primarily the responsibility of the World Health Organization (Fairchild, Dawson, Bayer & Selgelid, 2017). This has become a strong concept that has shaped the healthcare in the past 20 years. Comprehension Medical ethics and public health ethics are very similar concepts. Medical ethics could be considered the ethical principle between an individual and healthcare providers. Public health ethics, therefore, would be the ethical principles that are associated with the healthcare of the general public and typically involve organizations that strive to enforce ethical practices towards public health. The meaning between these two topics is to provide the utmost of care to an individual and public’s health by using moral principles and professional knowledge to deliver that care. It is the responsibility of healthcare providers, organizations and governing bodies to develop, enforce and adhere to ethical healthcare practices for the public as well as for each individual. Application Ethics is an important topic in the healthcare field and many lawsuits have come from an ethical standpoint. In 1992, a two-year old girl with an incurable glioblastoma was taken off her ventilator over the objection of her parents, while they were seeking legal redress (Courtwright & Rubin, 2017). The patient died two days later due to respiratory failure and the parents sued on multiple grounds, many that challenged the medical ethical principles that the hospital broke such as justice, autonomy as well as deprivation to practice religious rights. Although this case provided a settlement without admission of wrong-doing, it did bring up many ethical and legal issues that surround the healthcare field. The hospital acted in what they thought was the best interest of the patient. Due to the difficult nature of ethics, deciding what the best choice and decision is hard to determine. Analysis Although the patient in the previous example was unable to consent for herself, the parents are the ones who are responsible for her well-being and have control of her healthcare. However, the hospital believed it was in the best interest of the patient to remove her from the respirator since that was the only thing keeping her alive. This is the problem and the root cause of ethics, whether public health, medical or any other type of ethics. One may believe it is the best interest of an individual or a group of people for one action to be performed, while others believe the alternative is the best option. Because beliefs vary from person to person, ethics can be difficult to determine the best options. This causes healthcare providers to provide a list of policies and procedures that may cover ethical issues that may arise so there are no questions as to whether the healthcare facility broke any code of ethics. Medical ethics and public health ethics are separated for many reasons, primarily because medical ethics is suboptimal for assessing community-level public health interventions in the area of emergency preparedness (Swain, Burns & Etkind, 2008). They should be separated for this reason. They can be combined if they address both the needs of both the public health and the personal interactions between patient and physician. Synthesis Living in a healthcare world where we need to be educated of all religions, ethnicities, advance directives and other moral-based forces, it can be challenging to make ethical decisions to meet healthcare needs of all types of patients. There may be protocols and policies that cover ethical dilemmas, however what would be the best decision for one person, may not be the best decision for the next, solely based on their personal beliefs. Because of this, ditching the old universal ethical policy of autonomy, non-maleficence, beneficence and justice (Williams & Torrens, 2008). There should be a new universal methodology of medical ethics that allow any healthcare professional to make the best medical decisions based on proven science and medical knowledge and not on the patient’s beliefs. Decisions made will not bring forward any repercussions unless it does physical harm to the patient. Evaluation People go to healthcare providers for healthcare needs and healthcare providers should be able to provide care without the worries and repercussions of making a decision that could go against a person’s beliefs. Giving patient’s too much autonomy prevents many children from being unvaccinated, life-saving treatments from not being performed and many other incidences that can occur. The Chinese culture, for example, views mental illness as being shameful towards the individual and families and greatly affects psychological distress (Wang, Wong & Chung, 2018). A teenager who has an obvious mental disorder that needs psychological treatment may be discharged from the hospital without treatment because the patient and family will refuse treatment because of the negative stigma mental health brings in the Chinese culture. These situations would be eliminated because this patient would need to get the care the healthcare deems appropriate because it is in the best interest in the mental and physical health of the patent regardless of their belief system. A downside of this new idea would be the difficulty of making this a universal policy, especially for those hospitals that have religious-affiliation that may not agree with this methodology. Patients may also feel their freedom is being infringed upon, however they have the right to not seek medical care. But once the patient seeks medical care, they should trust the professionals to deliver care that is best for the patient and public as a whole and not on an individual’s beliefs. Post Two Knowledge: Every day, patients, families, and healthcare professionals are faced with ethical and legal decisions. Understanding the importance of ethics is crucial due to the fact that they come into play when dilemmas arise over medical treatments, practices, and hospital management. Healthcare ethics refers to a set of moral principles, beliefs and values that guides us in making choices about medical care (Medscape, 2019). When it comes to public health and medicine, ethics share some similarities but ultimately focus on different goals. Public health ethics applies to issues affections populations and their perspective is populationbased when involved with conditions or problems that give preeminence to the needs of the whole society (Williams & Torrens, 2008). On the other hand, ethics in regard to medicine focuses on individuals and paying exclusive attention to the interests of single individuals (Williams & Torrens, 2008). Comprehension: Public health and medicine each have their own set of ethics that the practice by. When referring to medical ethics, the focus is on the individual while on the other hand public health ethics focuses on the population. When issues arise related to medicine, healthcare professionals follow four basic values or principles when deciding on ethical issues. These principles include, autonomy which focuses on the patients’ right to determine their own healthcare, justice meaning distrusting the benefits and burdens of care across society, beneficence which is doing good for the patient and nonmalfeasance which is making sure you are not harming the patient (Medscape, 2019). When it comes to ethical decisions, it should also respect the values and attitudes of patients. For example, if the patient opposes vaccinations or blood transfusions for their child, their beliefs have to be taken into account, regardless if the healthcare professional agrees or not (Medscape, 2019). Application: Due to ethics being implemented, written standards have been created that pertain to certain professionals or organizations. Two examples of public health ethical standards are The American Public Health Association (APHA) and the Public Health Leadership Society. As far as two ethical standards examples for medicine healthcare personnel would turn to either The American Medical Association (AMA) which is an ethical standard for physicians or The American Nursing Association which is the standard for the nurses. Even though there may be similarities between the two standards, there are a lot of differences in which they approach the delivery of care that needs to be considered. Regardless of the differences between the two, the ultimate goal of medical ethics is to protect and defend human dignity and patients’ rights (Sokol, 2018). One ethical issue that is on the rise with the increases in the elder population due to the Baby Boomers, is end of life decisions. The populations are ageing and the ability to keep desperately sick people alive is ever-increasing. Ethical issues that healthcare professionals are faced with is should they help those individuals who want to end their lives, or should it be only those who are terminally ill or should it include psychiatric diseases? (Sokol, 2018). A good example of this ethical issue is Aurelia Brouwers a Dutch woman who was so unhappy with her mental suffering and described it as unbearable that she decided to lawfully drink lethal poison in the Netherlands (Sokol, 2018). Analysis: End of life is a touchy subject especially when the patient is asking for assistance. The question of whether severely ill suffering patients are entitled to a physician’s help to end their suffering by ending their lives has been debated since the Middle Ages (Quill & Sussman, 2018). The Hippocratic Oath suggests that this is outside of the physician’s professional responsibilities. Currently there are only 7 states who are legally practicing PAD while the rest of the country remains conflicted over this issue. A majority of physicians who favor legal access to PAD, only 30% would be willing to directly provide such assistance (Quill & Sussman, 2018). The code of ethics states that physician-assisted suicide is fundamentally incompatible with physician’s role as a healer, and it would be impossible to control and pose serious societal risks (web). Instead the solution is for physicians to aggressively respond to the needs of patients at the end of life by not abandoning the patient once it is determined the cure is impossible, respect patient autonomy and provide good communication and emotional support and lastly must provide appropriate comfort care and adequate pain control (Quill & Sussman, 2018). Synthesis: If as healthcare professionals they want to be sure adhere to ethics, then PAD should be legalized in all states. It is the patient’s autonomy what they want to decide when it comes to themselves and their healthcare options. Currently the State of Oregon is a great example of how PAD works since it has been in effect since 1998. Once made legal in every state, there should be a procedure written out that physicians would need to follow in order to assist the patient in such process. Currently in the State of Oregon, the physician writes the prescription and it is up to the patient to fill that prescription and then take it when and where they see fit. If legalized it should be standardized that the patient must fill the prescription or the POA, the prescription should have an expiration time of when it must be filled otherwise the patient will not be able to get another prescription for 3 months or unless current illness does not permit patient to live that long. Hospitals should have a room where these patients and their family can go through the process but also have a nurse available in case something goes wrong, if the patient choose to undergo the process in their own home, then a nurse must also be present and available in case of emergencies. This way having a nurse present they can help facilitate the next steps once the process is over with. Evaluation: The AMA has published a code of ethics section regarding this subject. It states that it is understandable, though tragic, that some patients in extreme duress, such as those suffering from a terminal, painful, debilitating illness, may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good (AMA, 2019). However, allowing patients to have that choice allows them the freedom and also ethically medicine is standing behind the patient every step of the way. The issue with legalizing PAD is who would pay for the prescription medication and for the nursing staff needed to be present. The medication can range from $30005000, which means does the insurance companies take the hit and fully cover the medication for the patient or does the patient have to fully pay for the medication if choosing this option. Alternative options should be provided to the patient for their information when taking such a delicate decision. Also support groups need to start being implement or those choosing this process and for their loved ones after the process is over. Post Three Knowledge Ethics is a “code” or set of standards that must be upheld those involved. The ethics could be such things as the Hippocratic Oath for physicians or the Florence Nightingale Pledge for nurses. There are also ethics at organizations and industries. There will be some commonalities among these ethics but there will so be some individual differences for each organization or industry. Ethics do not factor in morals or beliefs, yet ethics are a standard for which a profession, organization, or industry abide by. The individuals within these are to uphold the individual ethics as long as the individual is practicing or working within that setting. All of this holds true to the healthcare industry. There are similarities and differences in the ethics for physicians and nurse, for an individual organization, and the different industries within the field of healthcare. One of those differences between public health ethics and medical ethics. Comprehension Public health and medicine each have its own set of ethics that each abides by. Generally speaking, medical ethics are between a patient and a physician and public health ethics are between institutions and populations (Swain, Burns, & Etkind, 2008). These two sets of ethics go by three different principles in their own way as their guidance. Those three principles are autonomy, beneficence, and justice (Williams & Torrens, 2008). The similarities can be seen because of their use of the same principles but the differences can be seen because the ethics were built around different “consumers”. Autonomy in medical ethics refers to a personal level of privacy and choice to each individual and their needs. Public health ethics also refer to privacy and choice of other or a population and in a way of protecting their well-being. Beneficence in medical and public ethics is essentially the same because both are doing the right thing for everyone and encouraging the well-being of everyone. The final principle of justice is what public health ethics is rooted in. Public health is about serving the total population with concern for the equity of countless social groups, protecting susceptible groups, compensating groups who have disadvantages related to health, and the shadowing of the entire health care system (Williams & Torrens, 2008). At the end of it all, both of these sets of ethics are similar in treating and protecting their own “consumers”. At this time, I do not think there is a need for a change in either of the ethics, but I do think there will be a future of conflict between the two because issues will arise. The conflict will be when does the protection of many outweigh the few or individual and vice versa. References Swain, G., Burns, K., & Etkind, P. (2008). Preparedness: Medical Ethics Versus Public Health Ethics. Retrieved on January 8, 2019 from, https://journals.lww.com/jphmp/Abstract/2008/07000/Preparedness__Medical_ Ethics_Versus_Public_Health.8.aspx Williams, S. J., & Torrens, P. R. (2008). Introduction to health services (7th ed.). Clifton Park, NY: Thomson Delmar Learning. Application Ethics is something that is important in many areas and not just in healthcare. When it comes to healthcare, ethics are important standards to protect individuals and populations. An example of these ethics put into best practice is in regard to smoking and smoke-free laws. In 2006, the Surgeon General stated that the only way to eliminate involuntary exposure to secondhand smoke is to eliminate smoking in indoor areas (CDC, 2016). By reporting this and creating smoke-free laws, public health ethics were put into play by stating it is better for more of the population than it is to allow people to continue to smoke indoors. Since that time 28 states have implemented comprehensive law where individuals are not allowed to smoke in public and workplaces, including restaurants, bars, and casinos (ALA, 2018). While the other 22 states have some laws but are not as strict as the comprehensive law (ALA, 2018). There are many public areas across the country where smoking is banned or there are designated areas for smoking. Public Health officials are still allowing smoker the autonomy to smoke but strict the area for the health of the non-smoking and pediatric populations. References ALA. (2018, September 7). Smokefree Air Laws. Retrieved on January 8, 2019 from, https://www.lung.org/our-initiatives/tobacco/smokefreeenvironments/smokefree-air-laws.html CDC. (2016, June 24). State and Local Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars — United States, 2015. Retrieved on January 8, 2019 from, https://www.cdc.gov/mmwr/volumes/65/wr/mm6524a4.htm Analysis In the example above the laws were implemented out of the benefit of the majority of the population. Some smokers may have seen this as having their right to smoke and the right to smoke wherever taken away. While it may seem that way to some individuals the law did not outlaw smoking. The law only banned individuals from smoking indoors due to the health effects of those around them. These laws were put in place to protect and increase the health of the public, including children, who do not choose to smoke. The laws still allow individuals the autonomy to smoke and have created justice for those who don’t. Secondhand smoke has been the cause of approximately 2.5 million deaths since 1964 (CDC, 2018). Secondhand smoke can still lead to heart disease, lung cancer, and stroke which is why these laws were put into place. The exposure to secondhand smoke leads to these health issues which is also an increase in healthcare costs. Therefore, it was the ethics and justice that caused these laws to be implemented. References CDC. (2018, January 17). Secondhand Smoke (SHS) Facts. Retrieved on January 9, 2019 from, https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/ge neral_facts/index.htm Synthesis Across the country, there are different smoke-free laws. There are some states that have comprehensive laws where no one is allowed to smoke indoors including place of work, restaurants, bars, and casinos. There are some states that have strict laws but their laws do not encompass all of these places. Then there are other states that do not have strict laws. This means there are a number of different laws and regulations across the country. I think that public health officials should create standard comprehensive laws across the country. This means that smoking will be banned in all indoor areas across the country including casinos and bars. This law will include vaping and e-cigarettes. The law will also require businesses and workplaces, who do not have a smoke free campus, create designated areas of smoking. This should be included because many smokers will step just outside of a building and smoke at the door where other individuals are coming and going. Evaluation These mandatory laws will lead to a healthier population due to the decrease in secondhand smoke exposure. It will also aid in lowering healthcare costs due to the decrease in secondhand exposure. This law will also decrease missed work days due to secondhand smoke. It is estimated that the economic losses of $5.6 billion a year due to lost productivity (ALA, 2018). These laws may cause conflicts and even lawsuits from individuals and companies or businesses across the country. This is possible because individuals could see this as their rights being taken away and could deem it unconstitutional. There could be individuals who will have no regard for the law and smoke anyway. This will cause legal issues and even safety issues for individuals near the situation. There is also the possibility of individuals created “underground” or illegal establishments to allow individuals to continue to smoke in The big unexpected consequence is that is law will affect businesses and the economy. There are cigar lounges and casinos across the country that will see a decrease in business leading to economic issues for that business. This could mean bankruptcy for some businesses and decreased revenue for some areas such as Las Vegas. Instructions: This assignment must be done in APA format. A minimum word count of 1600 for the overall assignment (without references included) is required. A minimum of four (4) scholarly references along with in-text citations is also required for this assignment. However, each question ask for different things so please pay attention. Also, although this assignment is in APA format; please keep the question and answer line up (see example below) For Example: Question: XYZ Answer: XYZ Reference: XYZ Note: Please FOLLOW instructions and keep the above format. Each question is separate. DO NOT COMBINE. 1. Knowledge: What are the two key differences between medical / personal ethics and public health ethics? 2. 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? 3. 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. 4. 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 5. 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? 6. 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? Instructors Note: Each of these needn’t be long or expansive. Brevity is the soul of wit (Shakespeare). Practice efficiency and directness in your answers. Get to the point quickly. Avoid unnecessary “backfill”. Every word needs to make a contribution to the end points that you intend to make. Part Two Write a 150 word response to each discussion post. A minimum of two references per post is required. In-text citations must be included and cited properly. Note: Write the response as if you are talking to a person in person. Post One Knowledge Public health ethics and medical ethics have similar principles, but in different aspects. Public health ethics includes autonomy, right of privacy and freedom of action in society (Williams & Torrens, 2008). Medical ethics on the other hand focuses on an individual’s privacy, individual liberty, freedom of choice and selfcontrol of the individual in a medical setting. Medical ethics is the main driver of informed consent. Public health ethics put a strong emphasis on the community and the duty to take action in the name of the population well-being, which is primarily the responsibility of the World Health Organization (Fairchild, Dawson, Bayer & Selgelid, 2017). This has become a strong concept that has shaped the healthcare in the past 20 years. Comprehension Medical ethics and public health ethics are very similar concepts. Medical ethics could be considered the ethical principle between an individual and healthcare providers. Public health ethics, therefore, would be the ethical principles that are associated with the healthcare of the general public and typically involve organizations that strive to enforce ethical practices towards public health. The meaning between these two topics is to provide the utmost of care to an individual and public’s health by using moral principles and professional knowledge to deliver that care. It is the responsibility of healthcare providers, organizations and governing bodies to develop, enforce and adhere to ethical healthcare practices for the public as well as for each individual. Application Ethics is an important topic in the healthcare field and many lawsuits have come from an ethical standpoint. In 1992, a two-year old girl with an incurable glioblastoma was taken off her ventilator over the objection of her parents, while they were seeking legal redress (Courtwright & Rubin, 2017). The patient died two days later due to respiratory failure and the parents sued on multiple grounds, many that challenged the medical ethical principles that the hospital broke such as justice, autonomy as well as deprivation to practice religious rights. Although this case provided a settlement without admission of wrong-doing, it did bring up many ethical and legal issues that surround the healthcare field. The hospital acted in what they thought was the best interest of the patient. Due to the difficult nature of ethics, deciding what the best choice and decision is hard to determine. Analysis Although the patient in the previous example was unable to consent for herself, the parents are the ones who are responsible for her well-being and have control of her healthcare. However, the hospital believed it was in the best interest of the patient to remove her from the respirator since that was the only thing keeping her alive. This is the problem and the root cause of ethics, whether public health, medical or any other type of ethics. One may believe it is the best interest of an individual or a group of people for one action to be performed, while others believe the alternative is the best option. Because beliefs vary from person to person, ethics can be difficult to determine the best options. This causes healthcare providers to provide a list of policies and procedures that may cover ethical issues that may arise so there are no questions as to whether the healthcare facility broke any code of ethics. Medical ethics and public health ethics are separated for many reasons, primarily because medical ethics is suboptimal for assessing community-level public health interventions in the area of emergency preparedness (Swain, Burns & Etkind, 2008). They should be separated for this reason. They can be combined if they address both the needs of both the public health and the personal interactions between patient and physician. Synthesis Living in a healthcare world where we need to be educated of all religions, ethnicities, advance directives and other moral-based forces, it can be challenging to make ethical decisions to meet healthcare needs of all types of patients. There may be protocols and policies that cover ethical dilemmas, however what would be the best decision for one person, may not be the best decision for the next, solely based on their personal beliefs. Because of this, ditching the old universal ethical policy of autonomy, non-maleficence, beneficence and justice (Williams & Torrens, 2008). There should be a new universal methodology of medical ethics that allow any healthcare professional to make the best medical decisions based on proven science and medical knowledge and not on the patient’s beliefs. Decisions made will not bring forward any repercussions unless it does physical harm to the patient. Evaluation People go to healthcare providers for healthcare needs and healthcare providers should be able to provide care without the worries and repercussions of making a decision that could go against a person’s beliefs. Giving patient’s too much autonomy prevents many children from being unvaccinated, life-saving treatments from not being performed and many other incidences that can occur. The Chinese culture, for example, views mental illness as being shameful towards the individual and families and greatly affects psychological distress (Wang, Wong & Chung, 2018). A teenager who has an obvious mental disorder that needs psychological treatment may be discharged from the hospital without treatment because the patient and family will refuse treatment because of the negative stigma mental health brings in the Chinese culture. These situations would be eliminated because this patient would need to get the care the healthcare deems appropriate because it is in the best interest in the mental and physical health of the patent regardless of their belief system. A downside of this new idea would be the difficulty of making this a universal policy, especially for those hospitals that have religious-affiliation that may not agree with this methodology. Patients may also feel their freedom is being infringed upon, however they have the right to not seek medical care. But once the patient seeks medical care, they should trust the professionals to deliver care that is best for the patient and public as a whole and not on an individual’s beliefs. Post Two Knowledge: Every day, patients, families, and healthcare professionals are faced with ethical and legal decisions. Understanding the importance of ethics is crucial due to the fact that they come into play when dilemmas arise over medical treatments, practices, and hospital management. Healthcare ethics refers to a set of moral principles, beliefs and values that guides us in making choices about medical care (Medscape, 2019). When it comes to public health and medicine, ethics share some similarities but ultimately focus on different goals. Public health ethics applies to issues affections populations and their perspective is populationbased when involved with conditions or problems that give preeminence to the needs of the whole society (Williams & Torrens, 2008). On the other hand, ethics in regard to medicine focuses on individuals and paying exclusive attention to the interests of single individuals (Williams & Torrens, 2008). Comprehension: Public health and medicine each have their own set of ethics that the practice by. When referring to medical ethics, the focus is on the individual while on the other hand public health ethics focuses on the population. When issues arise related to medicine, healthcare professionals follow four basic values or principles when deciding on ethical issues. These principles include, autonomy which focuses on the patients’ right to determine their own healthcare, justice meaning distrusting the benefits and burdens of care across society, beneficence which is doing good for the patient and nonmalfeasance which is making sure you are not harming the patient (Medscape, 2019). When it comes to ethical decisions, it should also respect the values and attitudes of patients. For example, if the patient opposes vaccinations or blood transfusions for their child, their beliefs have to be taken into account, regardless if the healthcare professional agrees or not (Medscape, 2019). Application: Due to ethics being implemented, written standards have been created that pertain to certain professionals or organizations. Two examples of public health ethical standards are The American Public Health Association (APHA) and the Public Health Leadership Society. As far as two ethical standards examples for medicine healthcare personnel would turn to either The American Medical Association (AMA) which is an ethical standard for physicians or The American Nursing Association which is the standard for the nurses. Even though there may be similarities between the two standards, there are a lot of differences in which they approach the delivery of care that needs to be considered. Regardless of the differences between the two, the ultimate goal of medical ethics is to protect and defend human dignity and patients’ rights (Sokol, 2018). One ethical issue that is on the rise with the increases in the elder population due to the Baby Boomers, is end of life decisions. The populations are ageing and the ability to keep desperately sick people alive is ever-increasing. Ethical issues that healthcare professionals are faced with is should they help those individuals who want to end their lives, or should it be only those who are terminally ill or should it include psychiatric diseases? (Sokol, 2018). A good example of this ethical issue is Aurelia Brouwers a Dutch woman who was so unhappy with her mental suffering and described it as unbearable that she decided to lawfully drink lethal poison in the Netherlands (Sokol, 2018). Analysis: End of life is a touchy subject especially when the patient is asking for assistance. The question of whether severely ill suffering patients are entitled to a physician’s help to end their suffering by ending their lives has been debated since the Middle Ages (Quill & Sussman, 2018). The Hippocratic Oath suggests that this is outside of the physician’s professional responsibilities. Currently there are only 7 states who are legally practicing PAD while the rest of the country remains conflicted over this issue. A majority of physicians who favor legal access to PAD, only 30% would be willing to directly provide such assistance (Quill & Sussman, 2018). The code of ethics states that physician-assisted suicide is fundamentally incompatible with physician’s role as a healer, and it would be impossible to control and pose serious societal risks (web). Instead the solution is for physicians to aggressively respond to the needs of patients at the end of life by not abandoning the patient once it is determined the cure is impossible, respect patient autonomy and provide good communication and emotional support and lastly must provide appropriate comfort care and adequate pain control (Quill & Sussman, 2018). Synthesis: If as healthcare professionals they want to be sure adhere to ethics, then PAD should be legalized in all states. It is the patient’s autonomy what they want to decide when it comes to themselves and their healthcare options. Currently the State of Oregon is a great example of how PAD works since it has been in effect since 1998. Once made legal in every state, there should be a procedure written out that physicians would need to follow in order to assist the patient in such process. Currently in the State of Oregon, the physician writes the prescription and it is up to the patient to fill that prescription and then take it when and where they see fit. If legalized it should be standardized that the patient must fill the prescription or the POA, the prescription should have an expiration time of when it must be filled otherwise the patient will not be able to get another prescription for 3 months or unless current illness does not permit patient to live that long. Hospitals should have a room where these patients and their family can go through the process but also have a nurse available in case something goes wrong, if the patient choose to undergo the process in their own home, then a nurse must also be present and available in case of emergencies. This way having a nurse present they can help facilitate the next steps once the process is over with. Evaluation: The AMA has published a code of ethics section regarding this subject. It states that it is understandable, though tragic, that some patients in extreme duress, such as those suffering from a terminal, painful, debilitating illness, may come to decide that death is preferable to life. However, permitting physicians to engage in assisted suicide would ultimately cause more harm than good (AMA, 2019). However, allowing patients to have that choice allows them the freedom and also ethically medicine is standing behind the patient every step of the way. The issue with legalizing PAD is who would pay for the prescription medication and for the nursing staff needed to be present. The medication can range from $30005000, which means does the insurance companies take the hit and fully cover the medication for the patient or does the patient have to fully pay for the medication if choosing this option. Alternative options should be provided to the patient for their information when taking such a delicate decision. Also support groups need to start being implement or those choosing this process and for their loved ones after the process is over. Post Three Knowledge Ethics is a “code” or set of standards that must be upheld those involved. The ethics could be such things as the Hippocratic Oath for physicians or the Florence Nightingale Pledge for nurses. There are also ethics at organizations and industries. There will be some commonalities among these ethics but there will so be some individual differences for each organization or industry. Ethics do not factor in morals or beliefs, yet ethics are a standard for which a profession, organization, or industry abide by. The individuals within these are to uphold the individual ethics as long as the individual is practicing or working within that setting. All of this holds true to the healthcare industry. There are similarities and differences in the ethics for physicians and nurse, for an individual organization, and the different industries within the field of healthcare. One of those differences between public health ethics and medical ethics. Comprehension Public health and medicine each have its own set of ethics that each abides by. Generally speaking, medical ethics are between a patient and a physician and public health ethics are between institutions and populations (Swain, Burns, & Etkind, 2008). These two sets of ethics go by three different principles in their own way as their guidance. Those three principles are autonomy, beneficence, and justice (Williams & Torrens, 2008). The similarities can be seen because of their use of the same principles but the differences can be seen because the ethics were built around different “consumers”. Autonomy in medical ethics refers to a personal level of privacy and choice to each individual and their needs. Public health ethics also refer to privacy and choice of other or a population and in a way of protecting their well-being. Beneficence in medical and public ethics is essentially the same because both are doing the right thing for everyone and encouraging the well-being of everyone. The final principle of justice is what public health ethics is rooted in. Public health is about serving the total population with concern for the equity of countless social groups, protecting susceptible groups, compensating groups who have disadvantages related to health, and the shadowing of the entire health care system (Williams & Torrens, 2008). At the end of it all, both of these sets of ethics are similar in treating and protecting their own “consumers”. At this time, I do not think there is a need for a change in either of the ethics, but I do think there will be a future of conflict between the two because issues will arise. The conflict will be when does the protection of many outweigh the few or individual and vice versa. References Swain, G., Burns, K., & Etkind, P. (2008). Preparedness: Medical Ethics Versus Public Health Ethics. Retrieved on January 8, 2019 from, https://journals.lww.com/jphmp/Abstract/2008/07000/Preparedness__Medical_ Ethics_Versus_Public_Health.8.aspx Williams, S. J., & Torrens, P. R. (2008). Introduction to health services (7th ed.). Clifton Park, NY: Thomson Delmar Learning. Application Ethics is something that is important in many areas and not just in healthcare. When it comes to healthcare, ethics are important standards to protect individuals and populations. An example of these ethics put into best practice is in regard to smoking and smoke-free laws. In 2006, the Surgeon General stated that the only way to eliminate involuntary exposure to secondhand smoke is to eliminate smoking in indoor areas (CDC, 2016). By reporting this and creating smoke-free laws, public health ethics were put into play by stating it is better for more of the population than it is to allow people to continue to smoke indoors. Since that time 28 states have implemented comprehensive law where individuals are not allowed to smoke in public and workplaces, including restaurants, bars, and casinos (ALA, 2018). While the other 22 states have some laws but are not as strict as the comprehensive law (ALA, 2018). There are many public areas across the country where smoking is banned or there are designated areas for smoking. Public Health officials are still allowing smoker the autonomy to smoke but strict the area for the health of the non-smoking and pediatric populations. References ALA. (2018, September 7). Smokefree Air Laws. Retrieved on January 8, 2019 from, https://www.lung.org/our-initiatives/tobacco/smokefreeenvironments/smokefree-air-laws.html CDC. (2016, June 24). State and Local Comprehensive Smoke-Free Laws for Worksites, Restaurants, and Bars — United States, 2015. Retrieved on January 8, 2019 from, https://www.cdc.gov/mmwr/volumes/65/wr/mm6524a4.htm Analysis In the example above the laws were implemented out of the benefit of the majority of the population. Some smokers may have seen this as having their right to smoke and the right to smoke wherever taken away. While it may seem that way to some individuals the law did not outlaw smoking. The law only banned individuals from smoking indoors due to the health effects of those around them. These laws were put in place to protect and increase the health of the public, including children, who do not choose to smoke. The laws still allow individuals the autonomy to smoke and have created justice for those who don’t. Secondhand smoke has been the cause of approximately 2.5 million deaths since 1964 (CDC, 2018). Secondhand smoke can still lead to heart disease, lung cancer, and stroke which is why these laws were put into place. The exposure to secondhand smoke leads to these health issues which is also an increase in healthcare costs. Therefore, it was the ethics and justice that caused these laws to be implemented. References CDC. (2018, January 17). Secondhand Smoke (SHS) Facts. Retrieved on January 9, 2019 from, https://www.cdc.gov/tobacco/data_statistics/fact_sheets/secondhand_smoke/ge neral_facts/index.htm Synthesis Across the country, there are different smoke-free laws. There are some states that have comprehensive laws where no one is allowed to smoke indoors including place of work, restaurants, bars, and casinos. There are some states that have strict laws but their laws do not encompass all of these places. Then there are other states that do not have strict laws. This means there are a number of different laws and regulations across the country. I think that public health officials should create standard comprehensive laws across the country. This means that smoking will be banned in all indoor areas across the country including casinos and bars. This law will include vaping and e-cigarettes. The law will also require businesses and workplaces, who do not have a smoke free campus, create designated areas of smoking. This should be included because many smokers will step just outside of a building and smoke at the door where other individuals are coming and going. Evaluation These mandatory laws will lead to a healthier population due to the decrease in secondhand smoke exposure. It will also aid in lowering healthcare costs due to the decrease in secondhand exposure. This law will also decrease missed work days due to secondhand smoke. It is estimated that the economic losses of $5.6 billion a year due to lost productivity (ALA, 2018). These laws may cause conflicts and even lawsuits from individuals and companies or businesses across the country. This is possible because individuals could see this as their rights being taken away and could deem it unconstitutional. There could be individuals who will have no regard for the law and smoke anyway. This will cause legal issues and even safety issues for individuals near the situation. There is also the possibility of individuals created “underground” or illegal establishments to allow individuals to continue to smoke in The big unexpected consequence is that is law will affect businesses and the economy. There are cigar lounges and casinos across the country that will see a decrease in business leading to economic issues for that business. This could mean bankruptcy for some businesses and decreased revenue for some areas such as Las Vegas. CHAPTER 15 Ethical Issues in Public Health and Health Services* Pauline Vaillancourt Rosenau and Ruth Roemer H I G G S , CHAPTER TOPICS LEARNING OBJECTIVES S H Ethical Issues in Developing Resources A Ethical Issues in Economic Support Ethical Issues in Organization of Services N Ethical Issues in Management of Health I Services Ethical Issues in Delivery of Care C Ethical Issues in Assuring Quality Q of Care Mechanisms for Resolving Ethical Issues U in Health Care A Overarching Public Health Principles: Our Assumptions Upon completing this chapter, the reader should be able to 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 1 0 5 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 insoH 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 G as a whole.2 G Beneficence, which includes doing no harm, promoting the welfare of others, and doing good, isSa principle of medical ethics. In the public health , context, beneficence is the overall goal of public health policy and practice. It must be interpreted broadly, in light of societal needs, rather than narS rowly, in terms of individual rights. Justice—whether defined as equality of opportuH nity, equity of access, or equity in benefits—is the A core of public health. Serving the total population, public health is concerned with equity among N various social groups, with protecting vulnerable I populations, with compensating persons for sufferC ing disadvantage in health and health care, and with surveillance of the total health care system. As Q expressed in the now-classic phrase of Dr. William U H. Foege, “Public health is social justice.”3 This chapter concerns public health ethics as disA 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 1 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 preeminence5to 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 H this chapter. A word of caution: space is short andI our topic complex. We cannot explore every dimension of G every relevant topic to the satisfaction of all readers. G whose We offer here, instead, an introduction goal is to awaken readers—be they practitioners, reS searchers, students, patients, or consumers—to the , 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 selectedSethical issues in public health and the provision of H personal health services. We shall examine our topic by way A developof components of the health system: (1) ment of health resources, (2) economic N support, (3) organization of services, (4) management of serI of the vices, (5) delivery of care, and (6) assurance 6 quality of care. C Q U A OVERARCHING PUBLIC HEALTH PRINCIPLES: OUR ASSUMPTIONS 1 1 We argue for these general assumptions of a public 0 health ethic: ■ ■ 5 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 efH fective and proven practitioners should be available if health resources permit it without sacrificing I other ethical considerations. The ethical principle G of autonomy here might conflict with that of eqG uity, which would limit general access to specialists in the interest of better distribution of health care S access to the whole population. The need for ample , public health personnel is another ethical priority, necessary for the freedom of all individuals to enjoy a healthful, disease-free environment. S Physician assistants and nurses are needed, and they may serve an expanded role, substituting for H primary care providers in some instances to alleviA ate the shortage of primary care physicians, especially in underserved areas. But too great a reliance N on these providers might diminish quality of care if I they are required to substitute entirely for physicians, particularly with respect to differential diagC nosis.9 The point of service is also a significant Q consideration. For example, effective and expanded health care and dental care for children U could be achieved by employing the school as a A 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 1of the individual must be balanced with social justice 0 and beneficence. In the past, the individual’s deci5 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 2000Hthe “One Florida” program that ended consideration I of race in university admissions and state contracts.16 G These state actions have significant ethical effects on the health system and underserved G communities. They contribute to a shortage of physicians in S minority communities, and they deny many minor, 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 forSequitable access to quality institutions and for fair H distribution of health care facilities takes priority over an A the prefindividual real estate developer’s ends or erences of for-profit hospital owners. N Offering a range of facilities to maximize choice suggests the I need for both public and private hospitals, community clinics and health centers, andCinpatient and outpatient mental health facilities, as well as Q long-term care facilities and hospices. At the same time, not-for-profit providers, on several U performance variables, do a better job than the for-profit A 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 1 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 5for 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 H of biomedical research involving human subjects. Ethical issues are handled by ethics advisory I boards, convened to advise the Department of G Health and Human Services on the ethics of biomedical or behavioral research projects, and G by institutional review boards of research institutions S seeking funding of research proposals. Both kinds , of board are charged with responsibility for reviewing clinical research proposals and for ensuring that the legal and ethical rights of human subjects on are protected.27 Finding researchers to serve S IRBs is a growing problem because about half of H all researchers have serious conflicts of interest due to 28 the fact that they serve as industry consultants.A An overarching problem is the conflict of interest N 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 pharmaC ceutical or biotechnology firm. In 2005, several sciQ entists at the National Institutes of Health resigned in the wake of a new regulation banning NIH scienU tists from accepting funding from pharmaceutical A 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 1 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 duty5of 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 H Nowhere is the public health ethical perspective clearer than on issues of economic support. PerI sonal autonomy and respect for privacy remain esG sential, as does beneficence. But a public health orientation suggests that the welfare G of society merits close regard for justice. It is imperative that S everyone in the population have equitable access to health care services with dignity, so, as not to discourage necessary utilization; in most cases, this means universal health insurance coverage. Forty-five million Americans lack healthS insurance, which makes for poorer medical outcomes H even though individuals without health insurance do receive care in hospital emergency roomsAand community clinics. Most of the uninsured are N 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 C 56 million or 27.8% by 2013.32 The Institute of Medicine has Q provided an up-to-date and thorough analysis of the scope of uninsurance and underinsurance in U America.33 The underinsured, those with coverage A 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 1 co-pays for example.34 From a public health perspective, financial 0 barriers to essential health care are inappropriate. Yet 5 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 lowH income workers contained in the current government system. With respect to Medicare, the Bush I Administration’s support of a voucher system enG abling the beneficiary to buy private insurance will induce healthy and affluent elderly to opt out G of Medicare, leaving Medicare as a welfare program S for the sick and the poor. With less income, Medi, care will be forced to cut services. Social solidarity between the young and the elderly are critical. As members of a society made up S of overlapping communities, our lives are intricately linked together. No man or woman is an island; not H even the wealthiest or most “independent” can exist A alone. The social pact that binds us to live in peace together requires cooperation of such a fundamenN 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 consumpC tion) without appealing to social solidarity. These Q lessons apply to health care as well. In 1983, the President’s Commission for the U Study of Ethical Problems in Medicine and BiomedA 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 1 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 5 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 thanHto ensure that health care is efficient and effective. I If managed care ends up constraining costs by depriving G individuals of needed medical attention (reducing G for inmedically appropriate access to specialists, stance), then it violates the ethical principle of S beneficence because such management interferes with doing good for the patient.54 If, managed care is employed as a cost-containment scheme for Medicaid and Medicare without regard to S quality of care, it risks increasing inequity. It could even contribute to a two-tiered health care H system in which those who can avoid various A forms of managed care by paying privately for their personal health services will obtain higherN quality care. I Historically, the advantages of staff-model managed care are clear: team practice, emphasis C on primary care, generous use of diagnostic and theraQ peutic outpatient services, and prudent use of hospitalization. All contribute to cost U containment. At the same time, managed care systems A 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 1 and risk selection.55 The ethical issues in the relationships 0 among physicians, patients, and managed care organizations include denial of care, restricted 5referral 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 greatH 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 G malpractice claims as physicians and hospital do 61 G not have legal shelter from responsibility. As more and more integrated health care delivS ery systems are formed, as more mergers of man, aged care organizations occur, as pressure for cost containment increases, ethical issues concerning conflict of interest, quality of care choices, and paS tients’ rights attain increasing importance. The principles of autonomy, beneficence, and justice are H severely tested in resolving the ethical problems facA ing a complex, corporate health care system. “ If medicine is for-profit,” as seems to be the case N 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.C Sometimes the two can both be served, but it is unQ likely to be the case in all instances. Surveys of business “executives admit and point out the presence U of numerous generally accepted practices in their A 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.”164 That both consumers and employers are concerned 0 about quality of care is clear from Paul Ellwood’s 5 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 anH other subject of debate. The principle of first come, first served may initially seem equitable.IBut it also incorporates the “rule of rescue,” whereby G a few lives are saved at great cost, and this policy results GThe costin the “invisible” loss of many more lives. benefit or cost-effectiveness analysis of health ecoS nomics attempts to apply hard data to administrative decisions. This approach, however,, does not escape ethical dilemmas because the act of assigning numbers to years of life, for example, is itself S is detervalue-laden. If administrative allocation mined on the basis of the number of years H of life saved, then the younger are favored over the older, A factors which may or may not be equitable. If one into such an analysis the idea of “quality” N years of life, other normative assumptions must be made as I to how important quality is and what constitutes C assign a quality. Some efforts have been made to dollar value to a year of life as a tool for administerQ ing health resources. But here, too, we encounter worrisome normative problems. DoesUability to pay deform such calculations?72 A 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 1 serve to authorizing health programs; they also remedy inequities and to introduce innovations in a 0 health service system. Effective legislation depends 5 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 H case of enforcement involves a Baltimore ordinance prohibiting billboards promoting cigarettes in areas I where children live, recreate, and go to school, enG acted in order to enforce the minors’ access law G banning tobacco sales to minors. The Baltimore ordinance has not been overturned despite the fact S that a Massachusetts regulation restricting advertis, ing of tobacco and alcohol near schools was struck down as unconstitutional by the US Supreme Court on the ground of preemption.79 S Thus, management of health services involves issues of allocating scarce resources, evaluating H scientific evidence, measuring quality of life, and A imposing mandates by legislation and regulations. Although a seemingly neutral function, manageN ment of health services must rely on principles of I autonomy, beneficence, and justice in its decisionmaking process. C ETHICAL ISSUES IN DELIVERY OF CARE Q U A 1 Delivery of health services—actual provision of 1 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 5 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 H 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 ethiG cally unfair and medically ill advised. It is no surG Act, prise, then, that the National Organ Transplant adopted in 1984, made it illegal to offer or receive S payment for organ transplantation. Yet the sale of organs for transplantation still exists. It, has even been advocated as a market-friendly, for-profit solution to the current supply problems.85 S organs One solution would be to make more available through mandatory donation H from fatal automobile accidents, without explicit consent of A societies individuals and families. A number of have adopted this policy of presumed consent beN 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 C justify ignoring the individual autonomy (preferQ ences) of the accident victim’s friends and relatives. Spain leads other nations regarding organ U donation with 33.8 donors pmp in 2003 by interpreting A an absence of prohibition to constitute a near-death patient’s implicit …
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