Five Ethical Challenges in Healthcare

July 7, 2010 - Providing good patient care and avoiding harm are the cornerstones of ethical practice. Healthcare workers want to do the right thing, but it isn’t always clear how they should proceed. Every situation is somewhat different, and ethical dilemmas can arise even when a hospital has policies in place to address them.

Healthcare Briefings spoke with a number of experts in medical ethics and got their opinions about the top ethical issues facing healthcare today--plus insights on how managers are dealing with them.

1.  Avoiding conflicts of interest. Doctors and nurses are often prime targets of promotions from pharmaceutical, medical device and equipment manufacturers. That’s why more hospitals are banning free-meal presentations, pens, notepads and other logo items, said Kirk Hanson, MBA, professor and executive director of the Markkula Center for Applied Ethics at Santa Clara University in California’s Silicon Valley. “Recent studies show that physicians’ behavior is even influenced by trivial freebies,” he said. Among these is a July 2007 report in Obstetrics & Gynecology that found, "Even small gifts produce in their recipients a disproportionately powerful willingness to reciprocate in some manner."

The industry has made some efforts at self-regulation, including the Pharmaceutical Research and Manufacturers of America, which published an updated code of conduct for interactions with healthcare professionals in January 2009, and the Council of Medical Specialty Societies which announced their own voluntary ethics code in April 2010, seeking to limit the influence of for-profit enterprises.  Despite these measures, new research in the June 2010 issue of Archives of Surgery shows many physicians don’t mind accepting free samples from drug companies or collaborating with medical device manufacturers. The same perception applies to meals and travel expenses. Of the 590 doctors and medical students who replied to the survey, 72.2 percent said that industry-sponsored lunches were appropriate.

While encouraging their clinicians to turn down giveaways and any compensation that might influence their decision-making, hospital management teams are also scrutinizing whether their trustees and boards of directors should be allowed to maintain financial ties to the institution or health system, such as selling their own goods or services. And amid healthcare reform’s emphasis on containing costs, hospitals and practices are taking a closer look at their purchasing employees’ favoritism for certain suppliers. “Very few hospitals have ethical guidelines to govern the behavior of their purchasing professionals,” Hanson said.

2. Balancing profit with serving patients and providing charity care. “Nurses are a scarce resource. So is cash. Healthcare organizations must balance the books to keep their doors open ― ‘No margin, no mission,’” said Nancy Berlinger, Ph.D., M.Div., deputy director and research scholar at The Hastings Center, a national nonpartisan bioethics institution.

Healthcare organizations need to take a long, hard look at how they make ethical decisions involving their business operations, she explained. Berlinger, who also teaches healthcare ethics at Yale University School of Nursing in New Haven, Conn., gave an example: “Should organizations invest scarce resources in profit-making areas that are likely to serve a relatively small number of patients, or in areas that will provide basic care to a larger number of patients?”

Many questions like this cannot be solved definitively, but they can be anticipated and managed, according to Berlinger. 

“It is crucial for healthcare institutions to support good care through ethically sound policy, clear and fair processes, and ongoing ethics education for patient care providers at all levels, and through access to a clinical ethics consultation service that can consult with clinicians on difficult cases.”

3. Wrestling with equal treatment vs. VIP treatment for donors and other influential people. Elite care for VIP patients such as financial donors, trustees’ family members, and other influential people in the community can take many forms. It may result in shorter waiting times or longer physician consultations, or it could mean that “the hospital administrator drops by to make sure they don’t have any problems and that their care is first-class,” said Hanson, a specialist in healthcare organizational ethics.

While ensuring the privacy of celebrities enters into the equation, “The question is whether consistently the hospital treats people who are wealthy, or who are donors, differently than the general public,” Hanson explained. Individual cases should be monitored and policies put in place to clarify expectations. 

4. Managing pediatric and geriatric patients who may not have decision-making capacity. In questionable situations, providers need to determine whether the patient understands his or her medical condition, “the benefits and burdens” of the treatment options, and “what would happen if the patient elected no treatment at all,” said Bruce White, D.O., JD, director of the Alden March Bioethics Institute at Albany Medical College in Albany, N.Y. The patient also should be able to rationalize in selecting one choice over another. If a patient can’t give informed consent to a medical provider, then the responsibility falls to his or her legally authorized representative. That person is supposed to decide based on the patient’s known preferences or best interest.

5. Addressing nurses’ moral distress about providing care with minimal benefit.  This distress, according to White, is “the anguish that bedside nurses feel upon providing care for some patients when there’s minimal medical benefit or quality of life.” Some nurses tend to patients on life support for years. “They’re asking themselves, ‘Why am I doing this?’” said White, who’s also director of the Ethics Consultant Group in Nashville, which provides services to hospitals and healthcare organizations. Caught in the crossfire, nurses may feel they’re hurting people rather than helping people. And it bothers them that others go without care due to lack of funding. “We’re robbing Peter to pay Paul, and the nurses at the bedside know that,” he said.

Examples like the Terry Schiavo case in Florida – in which the patient was kept alive and cared for in a vegetative state for 15 years, including a long, publicized legal battle involving family members with opposing points of view – showed how difficult these cases can be for everyone involved.

Berlinger emphasized the importance of helping nurses and other staff members deal with these kinds of issues.

“Care near the end of life should be a particular focus of an ethically sound organization,” she said, “as most cases referred for ethics consultations involve patients with life-threatening conditions, impaired capacity to make treatment decisions, or both. Institutional investment in advance care planning, which helps patients to identify and document their treatment preferences in ways that can guide care if they are unable to make decisions in the future, is one step institutions can take to prevent crises.”

General methods for ethical problem-solving

White pointed out that the Joint Commission requires each accredited hospital to have an “ethics mechanism” that helps staff deal with ethical dilemmas. This mechanism is generally an ethics committee. Ethics committee members or consultants should be available around the clock to assist employees, patients and families, and can be called on to help resolve a perceived conflict between the parties. These consultants need to be well grounded in the hospital’s policies and should have additional ethics training.

“Like healthcare delivery generally, ethics mechanisms are local and tailored to the specifics of the unique case and context under discussion,” said White.

Administrators and clinicians can also enhance ethical practices at their institutions through ongoing education and open discussion, said Joseph Carrese, M.D., MPH, a Johns Hopkins University associate professor of medicine who teaches clinical ethics to medical students and resident physicians. He also leads the monthly forum, “Ethics for Lunch,” which averages 70 participants representing disciplines such as nursing, social work and pastoral care in addition to medicine.

“Conference attendees engage in a discussion about an important issue in clinical ethics recently encountered at the medical center,” said Carrese, a core faculty member of The Johns Hopkins Berman Institute of Bioethics in Baltimore.

Blending a formal ethics policy and support mechanisms with a culture that allows people to discuss some of the gray areas of their practice can prepare clinicians to tackle many of these problems in stride.

“Understanding ethical practice--how to do good and avoid doing harm--involves recognizing the complexity of the patient care environment, which requires workers to respond and adapt to changing conditions as a normal part of work,” said Berlinger, adding, “The duty to plan, and to make plans that can work in practice, is an ethical obligation.”

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