Tuesday, January 13, 2009

Respecting Patient Plight and Hospital Mission

Rosemary Flanigan
January 13, 2009

Myra Christopher and I are teaching a class this week at the Kansas City University for Medicine and Biosciences. This is one of the three medical schools we have in KC and it has recently added a graduate degree in Bioethics. Terry Rosell is an adjunct faculty member there and we at the Center help him out from time to time.

Myra and I are to talk about ethics committees—an easy task—and I thought that the last hour’s case analysis should be in organizational ethics instead of clinical ethics—maybe because clinical ethics receives the major focus throughout the course.

So I looked in Kuczewski and Pinkus’ Casebook, and found one that the authors did NOT use as an ethics committee consult; instead, it is correspondence between the CEO and the CFO. I thought, “Why not have the CEO send the correspondence to the ethics committee?” and that’s what I did when I adapted the case. The ISSUE is non-payment of emergency room bills, especially prescription drugs.

I think it is a dandy ethical analysis to try to create measures that both respect the patient’s plight AND respects the mission of the hospital to act as good stewards of its resources.

HELP!!! What do you think?? (I’ll tell you some of the “CFO’s” suggestions later, but I see no reason why those suggestions couldn’t have been equally made by a good ethics committee.)

Please share and view comments by clicking here.

Labels: ,


Blogger risaden said...

It's hard to generalize, because it depends so much on what the medical issues are, what the drugs are, what the hospital's resources are. That said, someone within the system should be expected to assist the patient to utilize a more appropriate route for health care. Is there a "high-frequency ED SW" to try to sift through getting other resources for the patient? I think the hospital should devote some resources towards resolving the problem. If there is really no other way for this person to get healthcare or medications (we need to change the system!!!) then I think we have to provide care and medications that are appropriate. Is the medication a narcotic? I think it's ok to refuse narcotics (within reason, given the presentation) if there is reasonable effort to forwarn the patient and potentially contract with her/him about this policy. Another important strategy is to find out what this person's goals are medically. I don't think this gives us the right to refuse treatment, but it is important to engage the patient in a non threatening discussion regarding what goals are mutual and achievable within the ED setting. Even if coverage were not the issue, there are certainly limits on how much "primry care" can be provided in the ED.

Tuesday, January 13, 2009  
Blogger Practical Bioethics said...

This comment from John Lantos, MD:

The general problem with rationing – and we are talking about rationing – is to come up with a system that is fair and transparent.

Case-based ethics consultation is, generally, neither. There is no demand for or mechanism for consistency in ethic consultation. There is generally no transparency or procedural fairness, either. (that is, no rules of evidence, no guarantee that a patient will have appropriate counsel, no discovery process, no minutes, no body of case law that has precedent-setting value etc.)

Decisions are made ad hoc based upon the particular circumstances of the case and the moral impulses of the committee.

To avoid these problems, a system would have to prospectively articulate principles for rationing, make them public, defend them, and enforce them consistently.

The general problem for hospital administrations (and ethics committees who would become players in this) is that hospitals and their administrators are rightly concerned with the bottom line.

Whether they make money or lose money providing a particular treatment depends more on whether the patient is insured or can pay for treatment rather than on whether or not the treatment meets some general standard of cost-effectiveness or would be provided by a “wise steward” of societal resources.

Can we imagine a hospital (and its ethics committee) that would develop and apply resource allocation standards regardless of the patient’s ability to pay, and therefore regardless of whether the hospital was in a position to make money or lose money by providing the treatment?

Our entire health care finance system is based upon the idea that hospitals and their administrators should be profit-maximizers, among other things.

We trust the market more than we trust political processes. And to the extent that we oversee the market, using legal and regulatory systems, we generally do so in ways that empower patients to demand and receive services, not in ways that allow hospitals or HMOs or insurance companies to deny access.

So that a hospital CEO who consistently enforced a policy by which the hospital stopped providing profitable services in order to serve larger issues of societal justice would soon be out of a job and would likely be sued as well.

As Rosemary might say….HELP!

Friday, January 16, 2009  

Post a Comment

Subscribe to Post Comments [Atom]

<< Home