Healthcare Administration
Instructions: This assignment must be done in APA format. A minimum word count of 350 words for the overall
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assignment (without references included) is required. A minimum of two (2) scholarly references along with in-text citations is also required for this assignment. This assignment must be done using the six components: Knowledge, Comprehension, Application, Analysis, Synthesis, and Evaluation. Please be sure to be detailed but brief as possible. 1. Previously we discussed the differences between Public Health and Medical Care. In this section we are discussing “Ethics” (not morals or values or culture) of Public Health and Medical Care. Public Health not the public sector. Be certain that all of your posts are grounded in a codified standard of ethics which is cited. You can discuss how these ethical standards may support/differ from prevailing morals and diversity of beliefs but the foundation must be an ethical issue. Use professional ethical standards as your foundation not your own opinion. How are the ethics of “public health” different from Medical Ethics? Why? Cite at least two codified ethical standards for each side. Do not confuse “public health” with insurance, public services, and the government, Medicare or Medicaid. Start with a clear definition of “public health” and Medicine. What are the respective roles of differing ethical standards? Who is served by each? How might these differences be resolved? Can they be? Should they be? Morals are individual, family or religious positions. They vary from person to person, group to group. Ethics are standards promulgated by professions Beliefs vary from person to person and from time to time. They are not a basis for making ethical decisions. Values vary from person to person, group to group. They influence how ethical standards are derived but they are not ethics as not everyone has agreed to them Ethics for this class are behavioral standards that apply to professionals who agree to be governed by them. Here is a link you may find useful background for all ethics discussions in this course: https://www.google.com/?gws_rd=ssl#q=Key+issues+in+healthcar e+ethics Be certain to include two scholarly sources for each post or reply APA style Reply Instructors Note: Be certain to include at least two scholarly references to validate and support your positions and conclusions. APA style please 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 authorization for organ transplantation.86 This has not been the case in 1 the United States to date.87 1 Delivery of services raises conflict-of-interest questions for providers that are of 0 substantial public health importance. Criminal prosecution of 5 threefold fraud in the health care sector increased 88 between 1993 and 1997. In today’s T marketdriven health system, about half of all doctors reS of a port that they have “exaggerated the severity patient’s condition to get them care they think is 333 medically necessary.”89 Hospitals pressed by competitive forces strain to survive and in some cases do so only by less-than-honest cost shifting— and even direct fraud. A recent survey of hospital bills found that more than 99 percent included “mistakes” that favored the hospital.90 Class action suits claim that HMOs are guilty of deceiving patients because they refuse to reveal financial incentives in physician payment structures.91 Physicians have been found to refer patients to laboratories and medical testing facilities that they co-own to a far greater extent than can be medically justified.92 As the trend to make medicine a business develops, the AMA’s Council on Ethical and Judicial Affairs has adopted guidelines for the sale of nonprescription, health-related products in physicians’ offices, but problems remain.93 The purpose is to “help protect patients and maintain physicians’ professionalism.”94 The public health ethic of beneficence is called into question by unnecessary products and inappropriate medical tests. The practice of medicine and public health screening presents serious ethical dilemmas. Screening for diseases for which there is no treatment, except where such information can be used to postpone onset or prevent widespread population infection, is difficult to justify unless the information is explicitly desired by the patient for personal reasons (life planning and reproduction). In a similar case, screening without provision to treat those discovered to be in need of treatment is unethical. Public health providers need to be sure in advance that they can offer the health services required to provide care for those found to be affected. These are the ethical principles of beneficence and social justice. The tragic epidemic of HIV/AIDS has raised serious ethical questions concerning testing, reporting, and partner notification. The great weight of authority favors voluntary and confidential testing, so as to encourage people to come forward for testing, counseling, and behavior change. A study by the U.S. Centers for Disease Control and Prevention (CDC) concludes that confidential namesbased reporting of HIV has not deterred testing Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 334 and treatment.95 Nevertheless, concern about violation of privacy and possible deterrence of testing and treatment with confidential names-based reporting of HIV persists. This issue raises sharply the ethical conflict between the individual’s right to confidentiality and the needs of public health. Some guidance for resolving ethical questions in this difficult sphere is presented by Stephen Joseph, former commissioner of health for New York City, who states that the AIDS epidemic is a public health emergency involvH ing extraordinary civil liberties issues—not a civil I liberties emergency involving extraordinary public health issues.96 G Partner notification was at first generally disapG proved on grounds of nonfeasibility and protection of privacy, but in accordance with CDC guidelines, S some states have enacted legislation permitting a physician or public health department to notify, a partner that a patient is HIV-positive if the physician believes that the patient will not inform the S partner.97 With the finding that administration of AZT durH ing pregnancy to an HIV-positive woman reduces A the risk of transmission of the virus to the infant dramatically, CDC recommends that all pregnant N women be offered HIV testing as early in pregI nancy as possible because of the available treatC ments for reducing the likelihood of perinatal transmission and maintaining the health of the woman. Q CDC also recommends that women should be U counseled about their options regarding pregnancy by a method similar to genetic counseling.98 A The field of reproductive health is a major public health concern, affecting women in their reproductive years. Here the principles of autonomy, benefi1 cence, and justice apply to providing contraceptive 1 services, including long-acting means of contraception, surgical abortion, medical abortion made pos0 sible by development of Mifepristone, sterilization, 5 and use of noncoital technologies for reproduction. The debate on these issues has been wide, abrasive, T and divisive. Thirty-two years after abortion was S legalized by the U.S. Supreme Court’s decision in Roe v. Wade,99 protests against abortion clinics PART FIVE Assessing and Regulating Health Services have escalated. Violence against clinics and murders of abortion providers threaten access to abortion services and put the legal right to choose to terminate an unwanted pregnancy in jeopardy. The shortage of abortion providers in some states and in many rural areas restricts reproductive health services. The mergers of Catholic hospitals with secular institutions and the insistence that the merged hospital be governed by the Ethical and Religious Directives for Catholic Health Care Services means that not only abortion services are eliminated but also other contraceptive and counseling services (except for “natural family planning”), sterilization procedures, infertility treatments, and emergency postcoital contraception (even for rape victims).100 The Food and Drug Administration’s refusal to approve over-the-counter sales of emergency contraception, despite the approval of two scientific committees, is a particularly troubling ethical decision. We state our position as strongly favoring the pro-choice point of view in order to ensure autonomy of women, beneficence for women and their families faced with unwanted pregnancy, and justice in society. In the highly charged debate on teenage pregnancy, we believe that social realities, the well-being of young women and their children, and the welfare of society mandate access to contraception and abortion and respect for the autonomy of young people. The ethics of parental consent and notification laws, which often stand as a barrier to abortions needed and wanted by adolescents, is highly questionable. Economists estimate the cost of such laws to be around $150 million in Texas alone.101 Many other important ethical issues in delivering health care have not been discussed extensively in this chapter because of space limitations. There are three such issues that we want to mention briefly. First, the end-of-life debate is generally considered a matter of medical ethics involving the patient, his or her family, and the physician. But this issue is also a matter of public health ethics because services at the end of life entail administrative and financial dimensions that are part of public health and management of health services.The Terri Shiavo Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 15 Ethical Issues in Public Health and Health Services Case is an example where the potential alternative use of societal resources brings to mind the contradictions involved in end-of-life issues.102 Second, in the field of mental health, the conflict between the health needs and legal rights of patients on the one hand and the need for protection of society on the other illustrates sharply the ethical problems facing providers of mental health services. This conflict has been addressed most prominently by reform of state mental hospital admission laws to make involuntary admission to a H with immental hospital initially a medical matter, mediate and periodic judicial review as Ito the propriety of hospitalization-review in which a patient G advocate participates.103 The Tarasoff case presents another problem in providing mental G health services: the duty of a psychiatrist or psychologist to S warn an identified person of a patient’s intent to , kill the person, despite the rule of confidentiality governing medical and psychiatric practice.104 In both instances, a public health perspective favors S rights of protection of society as against the legal individuals. H Third, basic to public health strategies and effecA tive delivery of preventive and curative services are records and statistics. The moral and legal imperaN tive of privacy to protect an individual’s medical I requiring record gives way to public health statutes reporting of gunshot wounds, communicable disC eases, child abuse, and AIDS.105 More generally, Q the right of persons to keep their medical records confidential conflicts with society’s need U for epidemiological information to monitor the incidence A and prevalence of diseases in the community and to determine responses to this information. At the same time, it is essential, for example, that 1 an individual’s medical records be protected from abuse 1 resoluby employers, marketers, etc.106 A common tion of this problem is to make statistics 0 available without identifying information. Congress has adopted HIPAA (Health5Insurance Portability and Accountability Act) in 1996 T to protect the privacy of medical records. Only in 2003 S did these aspects of the law take effect, HIPAA limits who may see medical records, how the records 335 are stored, and even how they are disposed of when no longer needed. Compliance costs have been enormous.107 ETHICAL ISSUES IN ASSURING QUALITY OF CARE If a public health ethic requires fair and equitable distribution of medical care, then it is essential that waste and inefficiency be eliminated. Spending scarce resources on useless medical acts is a violation of a public health ethic.108 To reach this public health goal, knowledge about what is useful and medically efficacious is essential. As strategies for evaluating the quality of health care have become increasingly important, the ethical dimensions of peer review, practice guidelines, report cards, and malpractice suits—all methods of quality assurance—have come to the fore. Established in 1972 to monitor hospital services under Medicare to ensure that they were “medically necessary” and delivered in the most efficient manner, professional standards review organizations came under attack as over-regulatory and too restrictive.109 Congress ignored the criticism and in 1982 passed the Peer Review Improvement Act, which did not abolish outside review but consolidated the local peer review agencies, replaced them with statewide bodies, and increased their responsibility.110 In 1986, Congress passed the Health Care Quality Improvement Act, which established national standards for peer review at the state and hospital levels for all practitioners regardless of source of payment.111 The act also established a national data bank on the qualifications of physicians and provided immunity from suit for reviewing physicians acting in good faith. The functions of peer review organizations (PROs) in reviewing the adequacy and quality of care necessarily involve some invasion of the patient’s privacy and the physician’s confidential relationship Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. 336 with his or her patient. Yet beneficence and justice in an ethical system of medical care mandate a process that controls the cost and quality of care. Finding an accommodation between protection of privacy and confidentiality on the one hand and necessary but limited disclosure on the other has furthered the work of PROs. Physicians whose work is being reviewed are afforded the right to a hearing at which the patient is not present, and patients are afforded the protection of outside review in accordance with national standards. Practice guidelines developed by professional H associations, health maintenance organizations and I other organized providers, third-party payers, and G governmental agencies are designed to evaluate the G appropriateness of procedures. Three states— Maine, Minnesota, and Vermont—have passed legS islation permitting practice guidelines to be used as , a defense in malpractice actions under certain circumstances.112 Defense lawyers are reluctant to use this legislation, however, because they fear their S case will be caught up in a lengthy constitutional appeal. Such a simplistic solution, however, avoids H the question of fairness: whose guidelines should prevail in the face of multiple sets of guidelines A issued by different bodies, and how should accomN modation be made to evolving and changing stanI dards of practice?113 Beneficence and justice are involved in full disC closure of information about quality to patients. Q Health plan report cards aim to fulfill this role.114 Employers, too, could use report cards to choose U health plans for their employees, though some A studies suggest that many employers are interested 115 far more in cost than quality. How well reports actually measure quality is itself subject to de1 bate.116 These are discussed in Part 3 of this book. 1 Malpractice suits constitute one method of regulating the quality of care, although an erratic and 0 expensive system. The subject is fully discussed else5 where in this volume. Here we raise only the ethical issue of the right of the injured patient to compenT sation for the injury and the need of society for a S system of compensation that is more equitable and more efficient than the current system. PART FIVE Assessing and Regulating Health Services The various mechanisms for ensuring quality of care all pose ethical issues. Peer review requires some invasion of privacy and confidentiality to conduct surveillance of quality, although safeguards have been devised. Practice guidelines involve some interference with physician autonomy but in return afford protection for both the patient and the provider. Malpractice suits raise questions of equity, since many injured patients are not compensated. In the process of developing and improving strategies for quality control, the public health perspective justifies social intervention to protect the population. MECHANISMS FOR RESOLVING ETHICAL ISSUES IN HEALTH CARE Even in the absence of agreement on ethical assumptions, and in the face of diversity and complexity that prohibit easy compromise, mechanisms for resolving ethical dilemmas in public health do exist. Among these are ombudsmen, institutional review boards, ethics committees, standards set by professional associations, practice guidelines, financing mechanisms, and courts of law. Some of these mechanisms are voluntary. Others are legal. None is perfect. Some, such as financing mechanisms, are particularly worrisome. Although ethics deals with values and morals, the law has been very much intertwined with ethical issues. In fact, the more that statutes, regulations, and court cases decide ethical issues, the narrower is the scope of ethical decision making by providers of health care.117 For example, the conditions for terminating life support for persons in a persistent vegetative state are clearer, when the patient has an up-to-date living will. The scope of decision making by physicians and families is constrained. A court of law, therefore, is an important mechanism for resolving ethical issues in such cases. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. CHAPTER 15 Ethical Issues in Public Health and Health Services The law deals with many substantive issues in numerous fields, including that of health care. It also has made important procedural contributions to resolving disputes by authorizing, establishing, and monitoring mechanisms or processes for handling claims and disputes. Such mechanisms are particularly useful for resolving ethical issues in health care because they are generally informal and flexible and often involve the participation of all the parties. Administrative mechanisms are much less expensive than litigation and in this respect poH tentially more equitable. Ombudsmen in health care institutions I are a means of providing patient representation and adG vocacy. They may serve as channels for expression G families. of ethical concerns of patients and their Ethics committees in hospitals and managed S care organizations operate to resolve ethical issues involving specific cases in the institution., They may be composed solely of the institution’s staff, or they may include an ethicist specialized in handling S such problems. Institutional review boards, discussedH earlier, are required to evaluate research proposals for their sciA entific and ethical integrity. Practice guidelines, also discussed earlier, N offer standards for ethical conduct and encourage professional behavior that conforms to Iprocedural norms generally recognized by experts in Cthe field. Finally, financing mechanisms that create incenQ tives for certain procedures and practices have the economic power to encourage ethical conduct. PerU haps the highest ethical priority in health care in A the United States is the achievement of universal coverage of the population by health insurance. At the same time, financing mechanisms may 1 function to encourage the opposite behavior.118 As the health care system continues to1deal with budget cuts, greater numbers of uninsured 0 persons, and restructuring into managed care and integrated delivery systems, ethical questions loom5large, Perhaps their impact can be softened by imaginative T and rational strategies to finance, organize, and deS prinliver health care in accordance with the ethical ciples of autonomy, beneficence, and justice. 337 Ethical issues in public health and health services management are likely to become increasingly complex in the future. New technology and advances in medical knowledge challenge us and raise ethical dilemmas. In the future they will need to be evaluated and applied in a public health context and submitted to a public health ethical analysis. Few of these developments are likely to be entirely new and without precedent, however. Already, current discussions, such as that presented here, may inform these new developments. ENDNOTES 1 2 3 4 5 6 Beauchamp, T. L., & Childress, J. F. (1989). Principles of Biomedical Ethics. New York: Oxford University Press, especially chapters 3, 4, and 5; Beauchamp, T. L., & Walters, L. (1999). Contemporary Issues in Bioethics. Belmont, Calif.: Wadsworth, (chapter 1). Burris, S. (1997). The Invisibility of Public Health: Population-Level Measures in a Politics of Market Individualism. American Journal of Public Health, 87(10), 1607–1610. Foege, W. H. (1987). Public Health: Moving from Debt to Legacy. 1986 Presidential Address. American Journal of Public Health, 77(10), 1276–1278. Annas, G. J. (2004). American Bioethics: Crossing Human Rights and Health Law. Oxford University Press, p. 244. Another public health question is how threats to the environment should be reconciled with the need for employment. We acknowledge that issues in environmental control have an enormous impact on public health. Here; however, our focus is on the ethical issues in policy and management of personal health services. For a discussion of equity and environmental matters, see Paehlke, R., & Vaillancourt, R. P. (1993). Environment/Equality: Tensions in North American Politics. Policy Studies Journal, 21(4), 672–686. This outline is taken from Roemer, M. I. National Health Systems of the World, Vol. 1: The Countries. (New York: Oxford University Press, 1991). Financial resources are treated later in the section on economic support. Copyright 2008 Cengage Learning, Inc. All Rights Reserved. May not be copied, scanned, or duplicated, in whole or in part. PART FIVE Assessing and Regulating Health Services 338 7 8 9 10 11 12 13 14 15 16 17 18 For an example of the symbiotic relationship between ethics and law, see Annas, G. J. (1998). Some Choice: Law, Medicine, and the Market. New York: Oxford University Press; and Annas, G. I. (2004). American Bioethics: Crossing Human Rights and Health Law Boundaries. New York: Oxford University Press. Gebbie, Kristine, Merrill, Jacqueline, & Tilson, Hugh, H. (2002). The Public Health Workforce. Health Affairs, 21(6), 57–68. Roemer, M. I. (1977). Primary Care and Physician Extenders in Affluent Countries. International H Journal of Health Services, 7(4), 545–555. Moscovice, I., & Rosenblatt, R. (1999). Quality Iof Care Challenges for Rural Health. Published by Rural Health Research Centers at University of G Minnesota and University of Washington. Retrieved G October 17, 1999, from http://www.hsr.umn.edu/ S centers/rhrc/rhrc.html. McMahon, G. T. (2004). Coming to America— , International Medical Graduates in the United States. New England Journal of Medicine, 10; McMahon, G. T. (2002). Outward Bound: Do Developing Countries Gain or Lose When TheirS Brightest Talents Go Abroad? Economist, 28. H Regents of University of California v. Bakke, 438 A U.S. 265, 1978. University of Texas v. Hopwood, 78 F.3d 932 N (5th Cir. 1996), cert, denied, 116 S.Ct. 2581, 1996. I Gruntter v. Bellinger et al. no 02-241, 2003, The C U.S. Court of Appeals for the 6th circuit. Gratz v. Bollinger. Q The New York Times. June 24, 2003, National, U p. A25. Komaromy, M. Affirmative Action and the Health A of Californians, UCLA Center for Health Policy Research, Policy Brief, October 1996. Rosenau, P. V., & Linder, S. (2003). Two Decades of Research Comparing For-Profit and Nonprofit1 Health Provider Performance. Social Science Quar1 terly, 84(2), 219–241; Rosenau, P. V., & Linder, S. A Comparison of the Performance of For-Profit 0 and Nonprofit U.S. Psychiatric Care Providers 5 since 1980. Psychiatric Services, 54(2), 183–187; Rosenau, P. V. Performance Evaluations of For- T Profit and Nonprofit Hospitals in the U.S. since S 1980. Nonprofit Management & Leadership, 13(4), 401–423. 19 20 21 22 23 24 25 26 27 28 29 30 Bell, J. E. (1996). Saving Their Assets: How to Stop Plunder at Blue Cross and Other Nonprofits. The American Prospect, 26, 60–66. Dallek, G., & Swirsky, L. (1997). Comparing Medicare HMOs: Do They Keep Their Members? Washington, DC: Families USA Foundation. Claxton, G., Feder, J., Shactman, D., & Altman, S. (1997). Public Policy Issues in Nonprofit Conversions: An Overview. Health Affairs, 16(2), 9–27. Himmelstein, D. U., Woolhandler, S., Hellander, I., & Wolfe, S. M. (1999). Quality of Care in InvestorOwned vs. Not-for-Profit HMOs. Journal of the American Medical Association, 282(2), 159–163. Melnick, G., Keeler, E., & Zwanziger, J. (1999). Market Power and Hospital Pricing: Are Nonprofits Different? Health Affairs, 18(3), 167–173. Moy, E., et al. (1997). Relationship Between National Institutes of Health Research Awards to US Medical Schools and Managed Care Market Penetration. Journal of the American Medical Association, 278(3), 217–221. Gross, C. P., Anderson, G. F., & Powe, N. R. (1999). The Relation Between Funding by the National Institutes of Health and the Burden of Disease. New England Journal of Medicine, 340, 1881–1887; Varmus, H. (1999). Evaluating the Burden of Disease and Spending the Research Dollars of the National Institutes of Health. New England Journal of Medicine, 340, 1914–1915. Annas, G. J. (1989). Who’s Afraid of the Human Genome? Hastings Center Report, 19(4), 19–21. 422 USCS Secs. 289, 289a-1-6, 1994, 21 CFR Secs. 56-58, 1994. See Ladimer, I., & Newman, R. W. (Eds.). Clinical Investigation in Medicine: Legal, Ethical and Moral Aspects, An Anthology and Bibliography. 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Los Angeles: Health Insurance Policy Program, University of California Berkeley School of Public Health, and UCLA Center for Health Policy Research. Gilmer, T., & Kronick, R. (2005). It’s the Premiums, Stupid: Projections of the Uninsured through 2013. Health Affairs Web Special, pp. 143–151. Institute of Medicine (U.S.). (2004). Committee on the Consequences of Uninsurance. Insuring America’s health: principles and recommendations/ H Committee on the Consequences of Uninsurance, Board on Health Care Services, InstituteI of Medicine of the National Academies. Washington, G DC: National Academies Press. Institute of Medicine (U.S.). (2003). Committee G on the Consequences of Uninsurance. Hidden costs, S on value lost: uninsurance in America/Committee the Consequences of Uninsurance, Board on , Health Care Services, Institute of Medicine of the National Academies. Washington, DC: National Academies Press. S Institute of Medicine (U.S.). (2003). 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