Georgetown University Press, 1995 Copyright © 1995 by the Woodstock Theological Center Library of Congress Cataloging-in-Publication Data Seminar in Business Ethics. For permission to reproduce in whole or part, please write the Woodstock Theological
Center, Georgetown University, Washington, DC 20057-1137, or telephone (202) 687-3532, or
fax (202) 687-5835. Copies can be ordered from the Woodstock
Theological Center. THE WOODSTOCK THEOLOGICAL CENTER is a nonprofit research institute established
by the Society of Jesus to address topics of social and political importance from a
theological and ethical perspective. Interdisciplinary and ecumenical by design, the
Center engages in research, conducts conferences and seminars, and publishes books and
articles. Human rights, economic justice, the church as a social institution, and business
ethics are some of the public policy issues that Woodstock examines. Section III Personal Decisions in Individual Cases
Appendix A Request for Institutional Arrangements
That Support Ethical Behavior
"Ethical Considerations in the Business Aspects of Health Care" is the
product of two years of study and four major conferences of members of the health care
community and academia. It offers evaluations and recommendations for health care
professionals in the difficult ethical issues and questions that they face in the business
aspects of their practice on a daily basis. Those whose names appear on the previous pages were participants
in the process. Not every member of the group subscribes to every sentence in this
report, but all support its basic contents and sentiments, deeming its distribution within
the health care community and beyond to be useful. Their support does not involve any
organization with which they may be affiliated. They hope their shared experience and
insight may help other health care professionals who face similar ethical challenges. The continuing Woodstock Seminar in Business Ethics was
conceived in the fall of 1988, when a group of leaders in banking and finance, business
and government, academia and church began discussing ethical dilemmas in the conduct of
mergers and acquisitions. From those conversations came a publication, entitled Ethical Considerations in Corporate Takeovers (Georgetown University
Press, 1990). The group, thereafter, felt that deeper, systemic issues still needed to be
addressed, which led to a second two-year series of conferences, resulting in the
publication, Creating and Maintaining an Ethical Corporate Climate (Georgetown
University Press, 1990). The decision was made by the Woodstock Seminar in the spring of 1991 to focus on the
ethical issues that health care professionals face in the business aspects of their
practices. So, the Woodstock Theological Center convened a diverse group of health care
specialists, physicians, nurses, hospital executives, ethicists, policy makers, academic
policy analysts, and religious leaders to formulate a consensus statement on "Ethical
Considerations in the Business Aspects of Health Care." Although we recognize that
many agents participate in the provision of health care services (insurers, research
scientists, and employees of pharmaceutical companies, to name a few), for the sake of
focus and manageability, we decided to consider only the special ethical dilemmas facing
individual providers, such as physicians, nurses, and therapists, and executives of
institutions such as hospitals, clinics, and managed care organizations. The seminar members began in the fall of 1992 by sharing responses to the question,
"What are the most pressing and vexing ethical issues in the business aspects of
health care that you face on a day-to-day basis?" Many examples of ethical issues and
dilemmas were exchanged. In the spring of 1993, the second meeting analyzed these ethical
dilemmas, grouped them according to type, and began developing sets of principles that
could be used to resolve them. In the fall of 1993 and again in the spring of 1994, the
participants pushed their analysis further to reach agreement on the core principles and
norms health care practitioners should have in view as they move through deliberation and
decision. What came out of these efforts is to be found here in Section II (Ethical Framework) and Section III (Personal Decisions in Individual Cases). Section IV of this statement contains a practical
checklist of questions that health care providers can pose to themselves as they face the
various ethical problems that occur in the business aspects of their profession. We hope
these questions will suggest a path for reflection and a set of issues that should be
addressed in making ethical choices as well as in evaluating the moral appropriateness of
the decisions made. In the course of group discussions, it became clear that ethical issues arise not only
out of individual conflicts, but also out of institutional arrangements that create
certain conflicts. The institutional context within which health care professionals must
practice influences the kinds of issues, dilemmas, pressures, temptations, and constraints
they face. Indeed, social institutions and systems embody and express many of the ethical
norms, expectations, and standards of society. When those institutional arrangements
undergo significant change, as the health care system is doing today, old ethical dilemmas
may be alleviated, and new ones may arise. The group also came to believe that an ethic that will be helpful for health care
providers in their difficult daily decisions must be a social ethic that situates
individual choices within consideration of the common good. By itself, an individualistic
ethic will not suffice, just as a socially directed ethic, by itself, is inadequate. What
is needed is a balanced ethic that respects the individual, but takes into account the
essentially social dimension of human beings and behavior. Although society comprises
individuals, society is more than the sum of all of the individuals in that society.
Hence, a sound social ethic must acknowledge the interdependence of every person within
the larger community. For these reasons the participants in this project concluded that they could not
provide ethical guidance to individual practitioners while ignoring entirely the
institutional arrangements or health care systems within which decisions must be made. Thus, while it is not the goal of the project to recommend a health care plan for the
United States, we decided that it was appropriate to address the issue of health care
reform to offer some hopes and suggestions about institutional design features that the
group believes would make it easier for providers to make sound ethical choices. These
reflections are attached as an appendix. We hope that this statement, then, will serve as a guide to individuals who, in their
work as health care providers, are attempting to make decisions and set priorities in ways
that reflect the highest personal and professional standards. What follows represents a
consensus of the views of the participants in the project. The statement does not claim
nor intend to claim a single unanimous moral or religious foundation or perspective. It is
not a specific proposal for policies or regulations, but is rather an invitation to
personal reflection and moral commitment. For this publication we are grateful to the Seminar Steering Committee: Margaret M.
Blair, William J. Byron, S.J., James L. Connor, S.J., Sister Rosemary Donley, S.C., Alain
C. Enthoven, John Collins Harvey, M.D., John P. Langan, S.J., General Edward C. Meyer,
Ambassador Henry Owen, Lynn Sharp Paine, Edmund D. Pellegrino, M.D., Charles O. Rossotti,
Kevin A. Schulman, M.D., Patrick J. Scollard, Joshua M. Wiener, and Kevin W. Wildes, S.J.
Dr. Blair also served in the role of rapporteur. We are happy to acknowledge our gratitude to The
Robert Wood Johnson Foundation for financial support for this project. James L. Connor, S.J. The health care system in the United States is undergoing a very rapid and
all-encompassing transformation. While politicians and their policy advisors debate the
role that state or federal governments can or should play in this process, economic and
business considerations are driving a massive restructuring of the way health care
services are financed and delivered. Amid all the change, in the corridors of hospitals,
nursing homes, and medical centers, and in the offices of individual health care
professionals, managed care organizations, and insurance companies, health care
professionals must continue to take actions and make decisions daily about the business
aspects of their professional service. The changes in the industry, and the choices and
decisions they are forcing professionals to make, however, are raising increasingly
complicated and troubling ethical questions among thoughtful and responsible health care
professionals. As with all professions, society grants the practitioners and providers of health care
services special status, privileges, and power because of the specialized knowledge they
must have. In exchange, health care professionals are expected to assume certain
responsibilities and obligations, and to live up to certain standards of behavior. This
implicit, and sometimes explicit, agreement about the mutual expectations between
professionals and society forms a "covenant of trust." Codes of ethics are one
of the ways that this covenant is articulated. Today, the ethical questions facing health
care professionals are more difficult than they have ever been because the institutional
arrangements that formed the basis of the "covenant of trust" are undergoing
profound change. As the institutional context changes, new dilemmas arise that were not
contemplated in the old covenant, the guidance given by earlier professional codes of
ethics seems less and less adequate, and important values seem to be in jeopardy. As recently as fifty years ago, most patients paid for health care services in this
country directly, out of their own income, if they could. Although insurance pools to
which patients belonged paid for some medical services, this was the exception rather than
the rule. In some instances, "charity" care was provided by the health care
professional without charge, or financed by religious institutions, civic organizations,
or public funds. But again, this was the exception rather than the rule. While there have always been situations in which the capacity of hospitals or clinics
was insufficient to satisfy all of the demand, in earlier days, the set of tests and
therapies that could in theory be used was limited in comparison with the range of
possibilities available today. Expectations about what medical intervention could
accomplish were also more limited; many treatments, tests, or therapies that are now
considered necessary were then regarded as elective; and litigation over negative outcomes
was less likely. The codes of professional ethics that governed most practicing health
care professionals were designed to respond to the ethical dilemmas and temptations that
arise in this kind of environment. For example, in this largely bygone health care world, the decisions about whether to
treat a particular patient, or what tests or therapies to use, or what fees the
professional would be paid for those services, were regarded as private decisions between
the practitioners and their patients. Many ethical problems that arose for professionals
in this environment involved the potential conflict of interest between the needs and
interests of the patient and the desire of the practitioner to do research or to enhance
his or her income. Hence, a key issue addressed in earlier codes of ethics for physicians
and other health care professionals was the requirement that health care professionals put
the interests of their patients above their own interests, and care for all who need their
help "with equal concern and dedication, independent of [the patient's] ability to
pay." ["A Physician's Commitment to Promoting the Patient's Good,"
Pellegrino, Edmund D., and Thomasma, David C., For the Patient's Good: the Restoration
of Beneficence in Health Care, New York: Oxford University Press, 1988, pp. 205-206.] Ethics codes also called upon health care professionals to contribute their expertise
to solving community problems, such as preventing the spread of disease, administering
scarce health care resources in times of war or epidemic, and making health care policy.
And health care professionals have always been expected to provide some services without
charge to those who could not pay, and to assist in society's provision of care to the
indigent. Indeed, a significant portion of health care has been provided by persons who
saw their work as a religious vocation and who regarded health care as a form of ministry.
Various religious bodies in this country have established hospitals and administrative
systems that have seen the care of the poor as well of the members of their faith as an
essential part of their mission. In these ways, the social covenant between health care professionals and society has
always required professionals to consider the interests of their patients ahead of their
own personal interests. It was understood that service to individual patients would be
constrained by available resources, and set in the context of the needs of the larger
community, but such factors were external to the ordinary relationship between the patient
and the professional, and were not expected to be a routine source of ethical problems for
professionals. A number of developments in the technology of health care, and in the way health care
is delivered and financed, have changed and continue to change the terms of the social
covenant. These developments add new demands and in some cases qualify or condition old
ethical requirements: The presence of "third-party payers" in the health care system is the feature
of the current health care world that most significantly affects the ethical context of
business decisions by health care professionals. Whether the third-party payer is the
government or a private insurance provider, this system reallocates the costs of health
care and spreads the financial risks so that today both the patient and the provider are
shielded from the immediate cost of most patient care. In a third-party payer system, the
resources expended in treatment of one patient are drawn from pools of resources that must
serve many patients. Hence, the cost of a given test or treatment must be measured not
only in terms of the out-of-pocket cost to the patient receiving the services (which may
be trivial), but in terms of the cost in lost resources to the whole group. But when
patients pay no more than a small fraction of the full cost of their treatments, it
becomes easy for them to consume more health care services than they need, and for health
care providers to recommend more services than their medical judgment justifies. In such
an environment, it is no longer appropriate to consider the decision to spend resources
for the care of an individual patient as an exclusively private decision between that
patient and the practitioner. Today, fee-for-service practice is rapidly being replaced by other practice structures
including managed care organizations or group practices in which the physician or other
professional is compensated by a fixed-fee salary, or by a share in the revenues or
"profits" of the group, or by some other arrangement. A key feature of these
alternative compensation systems is that the professional is not necessarily paid more for
providing more services. These new arrangements alter the ethical landscape in several ways. For health care
institutions and professionals in group practices or managed care groups, it may no longer
be a private act of charity to accept a patient who cannot pay the usual fees. Physicians
and other practitioners in the group are under pressures to control costs, and often are
required to abide by practice guidelines and standards of treatment designed to limit the
use of resources in cases where the benefits are expected to be marginal relative to
costs. These rules and standards may at times be at odds with what the patient wants, and
even with what the practitioner judges to be in the patient's best interest. Finally, whereas professionals in a fee-for-service setting have a financial incentive
to provide excessive services, professionals practicing in a managed care environment
often face financial incentives to cut corners or reduce the services they provide. The
ethical challenge for the professional is to resist both sets of pressures, to make a
constant effort to provide precisely those services that are medically appropriate, while
respecting the desires of the patient and the realities of resource constraints. The effort to ensure quality care as well as to limit costs has produced a vast and
complex set of rules about the information that health care professionals must collect and
disclose to the government or to other third-party payers. Reimbursement rates may depend
not merely on the services the practitioner actually provides, but on the nature of the
illness or condition of the patient and the diagnosis. This means that information the
practitioner may have recorded only for scientific or therapeutic reasons in the past may
now be used to determine reimbursements, and therefore have important financial
implications for both the patient and the practitioner. The rapid advance in medical technology in the last few decades has made numerous
elaborate diagnostic procedures and therapies widely available. Many of these scientific
advances have significantly relieved human suffering. Others make it possible to prolong
life. But they have also helped to propel a rapid increase in the cost of treatment for
the sick and injured. These increased costs are not distributed evenly, either across the
population or over the life of any one individual. Individuals who are relatively young
and healthy still make very low claims on available health resources. But the health care
problems of a few individuals make enormous claims on the common resource pool. As the
upper limit on possible expenditures rises, more people have felt the need to be insured
against such extraordinary expenditures. But as more people have insurance against very
large outlays, the more likely each one is to feel entitled to resource-intensive and
often unproven technology when and if he or she has serious health problems. As a result,
demand has risen even faster than resources have expanded. The problem is exacerbated by
the fact that, especially in a fee-for-service environment, the physicians and other
health care providers may benefit personally from using the new technologies or providing
the new therapies. Finally, the existence and use by some of such new but costly
procedures encourage even those without insurance to believe they have a "right"
to them as well. The very success of new health care technologies has also increased the demand for
health care services indirectly by making it possible for many more people to live to much
greater ages. Since the elderly tend to have more health problems, the expansion of the
elderly population is driving up total health care expenditures. As health care technology has expanded, and prosperity has risen, a growing number of
previously untreatable human problems have been reclassified as medical problems. Health
care resources are now routinely called upon to help people cure, or deal more effectively
with such problems as infertility, minor "neuroses," minor allergies, or minor
weight problems, to reconstruct faces or figures, or to repair minor joint injuries so
that the "patient" can continue to engage in sports activities. Thus, the
expansion of what medical intervention can accomplish has led to a corresponding expansion
in what many people think medical intervention should be expected to accomplish, and a
corresponding expansion in interventions that many in society regard as health care
"needs." This places a severe burden on those health care professionals who, by
reason of their personal convictions or their religious values, view it as their ethical
obligation to care for all who "need" their help, independent of ability to pay.
The expansion of health care diagnostic and treatment possibilities has also opened up
significant profit opportunities to health care professionals and entrepreneurs.
Professionals can choose lucrative specialties, or can target niches within their
specialties, such as cosmetic plastic surgery or sports medicine, which are especially
profitable because many individuals are willing to pay high prices for these services,
even if they are explicitly excluded from coverage by insurance policies. As a result, the
health care field is increasingly being influenced by "marketing" practices, and
the line between attending to the health care needs of society and selling a consumer
product has increasingly been blurred. In U.S. health care, economic pressures and opportunities are driving many providers
into larger organizations, both for-profit and not-for-profit, that are sharply focused on
the bottom line. This can lead to greater efficiency and lower costs, but, especially if
profit becomes the overriding motivation, it can also lead to reduced service, lower
quality care, and little or no concern for providing uncompensated care. Even as the definition of "needs" has been expanding, a growing number of
people are deciding that, as a matter of social norms, all individuals should have some
sort of "right" or "entitlement" to some basic level of health care.
But our political system makes it very difficult for anyone in authority to address head
on any questions about what level of care constitutes an irreducible minimum human right,
or even what level should constitute a civil right that citizens and legal residents in
the United States would be entitled to receive. Yet, without some such discussion, there
seems to be no way to set an upper limit on how much of society's resources should be
spent in this way, and expenditures on the health care entitlements that have already been
promised to our citizens continue to rise. The question of where the resources should come
from to pay for entitlements already promised, let alone to provide some level of basic
care for all, is central to resolving the issue, but it has not been adequately addressed.
The general rise in public expectations about what medical intervention ought to be
able to accomplish has also increased the sense of disappointment and resentment when bad
outcomes occur. Combined with a growing sense of entitlement throughout society and the
tendency to use litigation to resolve disputes, this rise in expectations has increased
the threat of malpractice lawsuits hanging over the heads of health care professionals,
contributed to a resource-intensive style of practice as a form of defensive medicine, and
increased the cost of insurance coverage for clinical practitioners. Thus, the context in which health care professionals practice is changing in many ways.
Many physicians, nurses, hospital executives, and other health care professionals feel
that the current health care system is an ethical mine field, which former professional
codes of ethics never envisioned and therefore do not adequately address. Many feel a
sense of disappointment that their earlier aspiration to a life of service to others has
been obscured by the economics and the politics of health care, particularly as these are
manifest in large, heavily bureaucratic institutions. Many feel a strong sense of
alienation from the ethical and religious roots of their professional commitments. Today
as yesterday, most health care professionals believe that their primary obligation should
be to care for their patients. But they are seeking clarification and guidance about what
that may mean in practice. Do these new institutional and technological innovations,
especially third-party payment systems, impose limits on the primary obligation of a
physician or other health care provider to serve the interests of the patient? Do
providers, in fact, also have obligations to third-party payers, and if so what are they?
What about obligations to the institutions within which the providers function? What about
obligations to society at large? This changing context presents new conflicts and complexities, and redefines others, in
making ethical decisions with regard to the business aspects of health care. Some specific
issues are discussed in detail in Section III, but before addressing those issues, we turn
to what the group saw as the key principles, virtues, and dispositions required of any
ethical decision maker in the field of health care. Health care professionals have three different but interrelated sets of
responsibilities. The first and foremost responsibility of physicians, nurses, physicians' assistants,
therapists, health educators, executives of health care institutions, and other health
care professionals is to attend to the health needs of the individuals in the communities
they serve. Members of the Woodstock group appreciate that the socially accepted notion of
"needs" may change both over time and with the advancement of technology, and
that each professional may have a different idea about how to define the
"communities" he or she serves. But most members agreed that a community's
health care "needs" include appropriate and reasonable measures to prevent
serious illness or injury in the healthy, to cure or alleviate the suffering of the sick,
and to comfort the dying. The second set of responsibilities is to administer and use wisely the physical,
technological, financial, and human resources available to health care professionals for
use in meeting the needs of the communities they serve. The third set of responsibilities is for continued education, research, and scientific
advancement so that the quality of care available for patients, and the efficacy and
efficiency with which resources are used in that care, can be improved over time. Most health care professionals face all of these responsibilities in different forms
and at various times. And many professionals feel that they have a fourth set of
responsibilities as well: to educate the public as to its health care responsibilities and
work toward policies that support professionals in carrying out the first three
responsibilities. Although there may be lucrative financial opportunities for some health
care providers in carrying out these responsibilities, the pursuit of personal wealth for
the provider must always be subsidiary to these primary responsibilities. This section presents the attitudes and principles that project participants regard as
the basis for ethical decision making by health care professionals as they undertake these
responsibilities. Respect for human dignity is fundamental, providing a basis for compassion, honesty,
integrity, and confidentiality, each of which will be discussed separately. While there
are differences, often quite sharp, within our society about how to interpret and specify
this fundamental value, it is strongly affirmed within the major religious and
philosophical traditions of our pluralistic society. Compassion, in turn, provides the
basis for the central tenet of the social covenant between health care providers and
society: that health care professionals must be committed, first and foremost, to the
welfare of their patients. Individual health care providers should do whatever they can for their patients,
consistent with obligations to other patients and necessary institutional and resource
constraints. It is unethical for a provider to exploit the vulnerability of the patient in
order to enhance his or her own income or profits. Institutional health care providers also have a primary obligation to serve the needs
of their patients, and to support individual health care professionals by providing the
appropriate facilities, equipment, supplies, support staff, administrative systems, and
services, subject to the constraints of limited resources. This requires that they devote
attention to the structure of funding and the needs and requirements of shareholders,
creditors, donors, other investors, or third-party payers, as long as those efforts
support the primary goal of patient care. Finally, it is the job of executives and
trustees to develop and foster institutional cultures that are devoted to care of
patients. Whatever form the health care system takes, the Woodstock group believes that the new
social covenant must affirm that patient care is the primary goal and responsibility of
the system. Since respect for human dignity applies to each and every human being,
regardless of race, creed, political views, or age, this is a powerful ethical
consideration supporting the view that access to basic health care should be made
available to all. Concrete instances in which threats are currently posed to this primary
obligation will be discussed later in this document. Individual practitioners, as well as executives and trustees of institutional
providers, have an obligation to continue their education and familiarize themselves with
the requirements of "best practice" in their fields. Poorly trained, inexperienced, or misinformed physicians or other practitioners can do
harm to patients. They may also drive costs up by ordering unnecessary or inappropriate
tests, by misdiagnosing conditions, or by administering inappropriate treatments.
Humility, the recognition that health care practice requires lifelong learning, and
openness to accountability are needed to ensure professional competence. Executives and trustees serve patients and their health care needs by exercising
competently their responsibilities for managing hospitals and other health care facilities
or organizations. Their job is to foster a climate that rewards the delivery of quality
care and promotes cost-reducing innovations. To do this, they must also stay abreast of
such innovations at other institutions. "Competence" also is required in the institutional design and operation of
any health care system. Ethical dilemmas often arise, and their resolution is made
extremely painful, because of inadequacies in the reimbursement system, in reporting
requirements, or in other institutional demands. Society's covenant with health care
providers requires efficient, flexible, and realistically designed systems that promote
ethical practices, rather than making them more difficult. As professionals, health care providers have responsibilities not simply to individual
patients, but also to the community at large. In the absence of universal health care
coverage, there inevitably will be members of the community who cannot afford, and who
could not otherwise gain access to the resources necessary to cover the health care
services they need. Thus, one of the important ways that health care providers must
exercise their community responsibilities is by providing uncompensated or reduced-fee
service to needy patients and by working for public policies that enable poor or uninsured
people to receive adequate care. Managed care, group practice, and "for-profit"
institutions should make provisions for proportionate amounts of uncompensated and less
compensated care by the group or institution. As members of the medical profession,
for-profit medical centers should be particularly mindful of the high standards required
by the social covenant. Likewise, "not-for-profit" institutions should be
mindful of the fact that their not-for-profit status gives them tax benefits that they
have a moral obligation to use in service to the community. Health care professionals look to public institutions and the political process to
arrange for some form of universal coverage, and, short of that, to determine standards
for "fair shares" of uncompensated or reduced-fee care, to help provide the
necessary resources, and to clarify the limits of such responsibilities. Otherwise, the
ethical and financial burden on health care professionals becomes nearly insupportable. Health care professionals have an ethical obligation to report truthfully all relevant
information about a patient's condition, appropriate treatments, and their associated
costs, to the patient or designated guardian, or appropriate family member. They also have
a professional obligation to keep accurate and truthful medical records, and to provide
truthful and accurate information on official forms and documents required by third-party
payers. These requirements for honesty apply equally to individual practitioners and to
executives of health care institutions and organizations. A further obligation falls to
executives of hospitals and managed care organizations to foster a culture that encourages
honesty, and to avoid rules or oversight practices that may pressure practitioners into
deceitful reporting. Intellectual honesty is essential for professional competence. Health care
professionals should know what they know, and what they do not know. They should
acknowledge their doubts, and seek second and third opinions from their colleagues when
they are unsure of a diagnosis or proposed path of treatment. Executives of health care
institutions must likewise be honest with themselves and others about the competing
interests they serve. They should be open to new ideas, and should manage their
organizations in such a way that they would not be embarrassed to open their books to
anyone. The health care system should not undermine the integrity and honesty of individual
practitioners by introducing constraints or imposing reporting requirements that
compromise the practitioner's professional judgment. Physicians, nurses, and other health care professionals should not divulge the intimate
details of a patient's illness or condition without permission, except as required by law.
Exceptions should be considered only for the most extreme justifying reasons, as, for
instance, the threat of serious harm to the patient or to other individuals at risk by
exposure to the patient. Decisions in such cases should be subjected to intense ethical
scrutiny. Third-party payers should request only the information they need, and should
tightly restrict the use of personal information about individual patients. Patients
coming into the system for any reason should be alerted as to what information is
recorded, how it is used, who will have access to that information, and what these rules
may mean to the patient. Although health care professionals have a primary obligation in any given situation to
work for the best interests of their patients, they must also be mindful of their
responsibilities as stewards of the common resources used to care for all of the patients
in the communities each professional serves. Good stewardship requires, then, that
professionals think carefully about the relative costs and benefits of alternative
therapies and courses of treatment for their patients, counsel their patients about the
costs and benefits, and, if necessary, work with third-party payers to encourage the use
of treatments and therapies that are the most cost-effective. Good stewardship also requires that individual health care professionals keep detailed
and accurate records. They should also, where appropriate, assist public health
authorities in collecting information about the spread of disease or the effectiveness of
new therapies, and should provide information to executives of the health care system to
help improve the functioning of the system. Executives of health care institutions are responsible for a wide range of
administrative and financial accounting, providing useful information about services,
costs, and patient outcomes to physicians, patients, third-party payers, and government
regulators. Such information is necessary for billing, for quality assurance programs, for
negotiations with third-party payers over prices, and for external-relations activities
such as advertising or fund-raising. It is an obligation of society at large, however, to ensure that the health care system
does not impose an undue burden of complex, arbitrary, and capricious record-keeping and
reporting requirements on health care professionals. In this section, we consider five broadly defined types of dilemmas that are
representative of those that health care providers face very frequently in the current
health care system. The Woodstock group, using the principles listed in the section above, did not achieve
unanimity in every instance, but was generally able to reach consensus about ways these
dilemmas should be resolved. That agreement is what is reported below. We hope our
struggle with the issues provides guidance for other health care professionals who face
similar questions, sometimes on a daily basis. There are at least two ways in which this dilemma arises for health care professionals.
The first is a short-term crisis situation. The second results from a continuing resource
constraint on the capacity of a given practice or institution to provide uncompensated or
undercompensated care. Short-term crises in which resources are inadequate to meet all needs occur, for
instance, in time of war or natural disaster. They also occur in the U.S. today, most
often in the emergency departments of inner-city hospitals when several critically sick or
injured patients arrive simultaneously and lifesaving resources are not immediately
available to serve all of them. The group was able to agree on the following guidelines for resolving dilemmas of this
short-term crisis type:
Even outside an emergency or crisis situation, there are numerous occasions when
patients would greatly benefit from treatments whose costs exceed their ability to pay.
The Woodstock group was unanimous in its belief that the dignity and worth of all
individuals and the sanctity of human life impose an obligation on society to provide a
basic level of health care treatment to all. We also believe that the obligation is
greater in a prosperous society such as the United States. The question then comes down to
how health care providers can satisfy these obligations in the absence of universal health
care coverage. The Woodstock group starts its consideration of this question from a firm agreement on,
and commitment to, this basic principle: All health care professionals and institutions
have an obligation to provide some uncompensated or "undercompensated" care
(services for which the professional and the institution are not paid enough to cover
their full costs). And all have an obligation to attempt to determine their "fair
share" of such care. A decision to avoid any share in this burden constitutes a
failure to carry on a tradition of community service and personal compassion which is one
of the basic moral responsibilities of the health care profession. Beyond that, we agreed
to the following ancillary principles:
In recent years, a number of physicians and other health care professionals have
invested in testing facilities, clinics, or companies that provide specialized medical
services and then, occasionally or even frequently, refer their own patients to these
services. The ethical issues raised by such practices were among the most controversial
issues discussed by the Woodstock group. After much debate, the group decided that to
properly evaluate the ethical considerations of such practices it is necessary to
distinguish two different business contexts: the fee-for-service context in which the
physician or other professional earns separate fees for each service or cluster of
services provided to the patient; and the managed care, prepaid, or "capitated"
environment, in which the professional, or the HMO or group in which the professional
practices earns a fixed fee for providing care for a given patient, regardless of the
services provided. Within the fee-for-service context, it is necessary to distinguish between services
that are integral to the practice of the physician or professional, and ancillary services
that are outside the ordinary practice of the physician or professional, but to which the
professional may frequently, or occasionally, refer a patient. (If the service is so
remote from the practice of the professional that he or she will never have occasion to
refer a patient to that service, then there is little potential for conflict of interest,
and there would not normally be any ethical problems in a decision by the professional to
invest in the service.) Where the patient or third-party payers pay a separate fee for each service provided,
the practice by physicians and other professionals of investing in ancillary clinics,
testing facilities, or companies that provide specialized services sets up a conflict of
interest that seriously compromises the objectivity of the professional in referring
patients to those services. Because trust is so important in the practice of medicine,
even the appearance of a conflict of interest is corrosive and must be avoided. The crux of the dilemma is that the health care professional can generate investment
income for himself or herself by referring patients to the ancillary service. This
conflict of interest inherently compromises the objectivity of professional judgment,
which must be primary. Thus, referral of patients to facilities in which the referring
health care professional has an investment interest is almost always ethically
inappropriate. The Woodstock group believes that a health care professional's sources of
investment income should not be so intimately related to his or her professional practice
and primary source of income. The inherent conflict of interest in such cases is severe
enough that Medicare laws prohibit referral by a physician for clinical laboratory
services and many other health services if the referring physician has a financial
relationship with the firm providing the service. Nonetheless, there may be extraordinary circumstances where it would not violate
ethical principles for a physician or health care professional to invest in the
establishment of some ancillary clinic or service. For example, there may be some rural
environments where financing for such a facility or service would otherwise be unavailable
unless the professionals in the community invest out of their own resources. Professionals
who make such investments, however, might have to live with the fact that they will not be
reimbursed by Medicare if they refer their patients to those services. And they would have
an absolute ethical obligation to disclose their special interest to their patients, and
to the third-party payers. Finally, they should divest themselves of such financial
interests as soon as other investors can be identified to replace them. The above arguments apply to all services that are outside the ordinary practice of the
professional. Services that are an integral part of the practice of the professional,
which the professional directly supervises, or in which the professional otherwise
clinically participates, may be considered an extension of the practice of the
professional, and do not necessarily raise the ethical problems of self-referral. But even
these services raise concerns about the tendency of the professional in the
fee-for-service environment to overutilize services. As with all services provided by
health care professionals, each professional has an ethical obligation to recognize that
resources appropriated in the care of one patient are generally drawn from some common
pool, and therefore diminish, to some extent, the resources available to treat other
patients. Thus, professionals need to be mindful of the relative costs and benefits of all
the services they provide, and should develop the habit of practicing cost-effective
medicine. Where the ancillary services are not billed separately but are included in the fixed
charge to the patient, the Woodstock group found little reason to believe that conflict of
interest would be a problem for a physician or other professional in referring the patient
to those other services, even though the professional may have an investment interest in
those services. Indeed, because such referrals may result in extra costs, but no extra
income to the managed care group, ethical problems are more likely to arise because
financial considerations push the professional in the other direction, toward failing to
refer patients to other available services. Physicians and other health care professionals
working in such a system are obligated to provide, or advise their patients of the
availability within the group of all services that, in the unbiased judgment of the
professional, are medically appropriate. Physicians and other professionals must not
permit their judgment about medical appropriateness to be influenced by the possibility of
personal financial gain or loss, however. In the next section, we address other ethical
issues that may arise in such a context. Instances are arising ever more frequently in which a physician's or other health care
provider's proposed plan of treatment or therapy is denied funding by an insurance carrier
or other third-party payer. Two common areas of disagreement, for example, are the length
of hospital stays and referrals to specialists. Many third-party payers are attempting to
control costs by limiting reimbursements for hospital stays to the number of days needed
by an "average" patient with a particular condition. Third-party payers may also
agree to pay for treatment by a specialist only if the referral to the specialist was
approved in advance, and the specialist was drawn from an approved list. Such rules are
intended to limit expenses and distribute limited funds more equitably and efficiently
across the entire population that is insured by a given plan. The conflict, then, is
between a health care professional's best judgment for a particular patient and the
economic constraints imposed by the payer. When faced with such situations, we suggest the following guidelines:
Cases arise wherein reporting requirements of health care management, insurance, or
reimbursement systems may harm the patient or come in conflict with a patient's right to
or desire for confidentiality. One example that members of our group had actually
confronted was of an adolescent admitted to a hospital emergency room for a drug overdose.
The attending physician faced the following dilemma: the patient threatened suicide if the
provider told his parents or reported the incident accurately to the insurance company,
the effect of which would be that the young person's family would find out; but if the
admitting condition were not reported, the hospital and attending physicians would not be
compensated. Members of the group agreed to the following ethical guidelines in such situations:
An ethical dilemma arises for a health care professional when a patient's own behavior
contributes significantly to illness or injury. Is it fair to other patients and to the
community one serves to authorize repeated or intensive use of society's scarce resources
to respond to or counteract individual choices that are destructive or imprudent? Smoking, for example, is known to contribute to the probability of lung and heart
disease, riding a motorcycle without a helmet contributes to the severity of injuries in
the case of accident, and driving while intoxicated increases the probability of serious
injury. Likewise, patients who neglect to take their medications, or refuse to follow
dietary restrictions, may require repeated treatment when their symptoms recur or when
their illnesses fail to improve. We subscribe to the following guidelines for health care providers confronted with
treating patients who exhibit such behavior:
The pace of technological advance in health care is now such that there are always new
procedures and therapies available, and new applications of old technologies that show
promise in the treatment of some illnesses and conditions, but that have not yet been
sufficiently proven to be regarded as standard medical practice. The ethical issues in any
decision by a physician or other professional to recommend or administer such procedures
or therapies involve at least two different principles discussed in Section II. These are
the professional competence and the careful stewardship of resources. Each will be
discussed separately below. Physicians and other health care providers may benefit financially and in terms of
their reputations among their colleagues by being at the forefront of developments in
medical technology in their practices. But new developments are not necessarily better
medicine. Competence and commitment to the welfare of the patient require not just
technical proficiency, but attention to cost-effectiveness, and to the total impact of the
treatment plan on the patient. For example, some high-tech services may so reduce the
quality of life for patients that they would be equally well-served, or even
better-served, by less intrusive, less technology-intensive kinds of therapies even though
the latter may provide a smaller chance of full recovery. It is the ethical obligation of
the physician or other professional to weigh carefully, in consultation with the patient,
the cost-effectiveness of elaborate, highly intrusive, or new and unproven therapies,
where costs include the risks to the patient and the impact of the treatment on the
quality of life, as well as the cost in dollars. Third-party payers obviously have an interest in seeing that health care resources are
used in cost-effective ways and that reimbursements cover proven, efficacious therapies
rather than treatments that are experimental or unproven. On the other hand, especially
where there are no known therapies that are proven and efficacious, resources must be made
available to support testing of experimental treatments even while they are still under
development. (See recommendations in section H of Appendix.) Emerging technologies should
be subjected to rigorous scientific assessment before being made widely available to
patients. In the meantime, physicians and other health care professionals must be
attentive to the cost-effectiveness of new technologies. They should also participate in
clinical trials where appropriate, carefully record and share information with proper
authorities about the effects and side effects of the use of new therapies, and caution
patients against expecting or demanding unproven treatments. In view of the foregoing description and analysis, we provide here a checklist of
questions that individual health care professionals can and should ask themselves as they
confront the daily temptations and dilemmas of their practice and attempt to respond in a
manner consistent with the highest ethical standards of their profession. A. When deciding whom to treat, and how to allocate scarce resources in short-term
crisis situations:
B. When drawing up a mission statement or otherwise determining my private
commitment or institutional commitment to providing uncompensated or undercompensated
care:
C. When the needs of my patients or my community exceed my capacity to provide
uncompensated or undercompensated care:
D. When confronted with opportunities to invest in testing services or ancillary
medical services:
E. If, after careful consideration of the questions in D above, I decide to invest
in ancillary testing facilities, or medical service companies, then, in future dealings
with the firm that operates these facilities:
F. In administering resources and serving my patients in a cost-conscious way:
G. Whenever the rules and regulations of third-party payers conflict with my
professional judgment:
H. In the course of ordinary record-keeping and billing:
I. When truthfulness conflicts with patient confidentiality:
J. When patients' behavior contributes significantly to their problems:
K. Whenever I am troubled by decisions or actions I am taking:
The group that participated in this project argued vigorously over some of the
positions taken in this document, as well as over the precise language in which those and
other positions were expressed. The resulting document is not perfect, nor does it resolve
all of the issues in unambiguous ways. Rather, our results are more modest. We acknowledge
that certain ethical dilemmas will always exist in the field of health care as it relates
to business practices. And we suggest that, regardless of the systemic reforms that are
made, health care professionals must acquire or develop their own maps, compasses, and
other tools to help them find their own path through the ethical mazes they will confront.
Some of these tools and guides health care professionals will be able to find through
their previous education in the humanities and the social sciences; some they will find
through reflection on the religious and professional traditions that have seen health care
as much more than a business enterprise providing a consumer service; some they will find
by deepening their sense of the ultimate meaning of what they do and by renewing their own
commitment to the ideals and goals that first drew them into the work of health care. This document is intended to provide one such tool. We hope that other health care
professionals can benefit from our struggle to develop this tool. Finally, in the
following appendix, we ask that those who are instituting changes or reforms in the system
be sensitive to the ways in which institutional design can exacerbate certain dilemmas. The choices and decisions of health care providers are inevitably shaped by the
institutional and cultural context in which the providers operate. Institutional
arrangements embody certain cultural messages about what constitutes appropriate behavior.
Policies and customs can help to clarify responsibilities and support ethical decision
making, or they can exacerbate conflicts of interest, create incentives for unethical
choices, and undermine accountability. Because ethical decision making is so important to
healthy human relationships, institutional arrangements that send contradictory messages
about what is appropriate, or that undermine or discourage ethical decision making, are
socially destructive. We believe that one of the responsibilities of health care providers is to use their
influence, in collaboration with others, to create a health care system and institutions
within that system that will minimize unnecessary ethical conflicts of interest and
clarify priorities. Thus, we offer these observations about the ways that institutional
and systemic reforms can clarify the social covenant, and help create a climate that
fosters rather than frustrates ethical decision making. This is particularly important in
an area of human life that touches on so many matters that are of intimate personal
concern and of profound religious meaning. Belief in the fundamental dignity and worth of each individual leads members of our
group to a conviction that a civilized society has an obligation to provide compassionate,
humane care to every one of its members if they are injured or sick. To ensure that such
care is available to all, sufficient financial and social resources must be made
available. Too often, the existing health care system in the United States produces erratic and
highly arbitrary outcomes, with some individuals unable to get basic care, while others
expend enormous resources on therapies of marginal or questionable benefit. This places a
huge ethical burden on some members of the health care profession, such as emergency room
physicians and executives of inner-city hospitals, to determine who will get access to
certain resources. And it induces some professionals to evade any direct confrontation
with such tough decisions by locating their practices in settings where they are likely to
encounter only patients who have the means to pay for their services. The members of our group believe that health care professionals have a responsibility
to participate in decisions about allocating available resources. But it is the
responsibility of society as a whole, including both citizens and professionals working
through public debate and the political process, and not of individual health care
professionals alone, to determine what the minimum standards of care should be, and,
importantly, to seek to provide financial support to be sure that those standards can be
met. To date, our society has not yet solved this problem, and as a result, many decisions
about how much care is to be provided to whom are being made in an ad hoc way, adding
significantly to the ethical burden borne by health care providers. We ask, therefore, that public officials and leaders of the health care field confront
this issue directly. Medical professionals, health care consumers, taxpayers and other
third-party payers, and policymakers, should all join in a national conversation about
this issue. Political and professional debates should attempt to determine policies that
will provide a decent minimum of care for all, that will emphasize primary and preventive
health services, that will be responsive to the needs and choices of patients, and that
will use resources in ways that will be both fair and efficient. Once decisions are
reached, society must make available the resources necessary to achieve the distribution
of health care services that it has chosen to provide. In asking for definition of, and provision for, a basic minimum level of health care,
we acknowledge that there are limits to our nation's capacity to provide resources for
health care. Therefore, we agree that it is legitimate and appropriate for society to
impose some standards, limits, and rules about how resources are to be used. Otherwise, we
will have an unfair and morally objectionable distribution of services that will be
detrimental to the common good and the population as a whole. Participants in the policy debate should understand that any scheme for financing
health care that fails to provide some form of universal coverage has the effect of
forcing onto health care providers, in one way or another, the difficult decisions about
who should get what level of care under what circumstances. Moreover, all third-party
payment schemes are subject to certain distortions in the incentives of both health care
providers and their patients. These distorting incentives were discussed in Section I
under "Third-party payers," and "Managed care groups." No system can completely eliminate all of these dilemmas. But the Woodstock group asks
that health care entrepreneurs who are creating new payment and delivery systems for
health care, as well as participants in the policy debates about health care reform, be
mindful of the ethical dilemmas they may create as they choose one system or another. An
ethically defensible system will acknowledge the dilemmas, will encourage focus on the
interests of the patients and will attempt to provide guidance to the professionals about
what is expected of them. It will also build in safeguards to protect ethical behavior,
and sanctions against unethical behavior, even when ethical behavior may work against the
financial interest of the institution within which the professional works. The government should work with insurance companies and providers to develop
information about the social costs and benefits of various therapies and treatments. Such
information would help health care professionals understand the social costs of selected
paths of treatment and counsel patients about these costs and expected marginal benefits
of various treatments. If health care professionals must practice within an overall budget
constraint, they should be kept informed of the total budget, and the status of
expenditures within the budget, and should be allowed to participate in decisions about
reallocating resources within the budget. Together with the patients, then, health care
professionals will be better able to choose treatment paths that keep costs as low as
possible, consistent with good care for the patients. Physicians and other providers who must occasionally refer their patients to other
physicians or specialists, especially if their work arrangement requires them to choose
providers from within a limited group, must have the necessary information to make a
judgment about the competence of the various providers from whom they must choose.
Therefore, we recommend that government agencies, insurance companies, and provider
associations work together to develop appropriate performance measures. Information about
how individual providers rank in terms of these measures should be available to physicians
and other providers who must make referrals. Schools of the health professions should teach physicians and other providers how to
conduct peer review and how to interpret various performance measures. Providers must often play multiple roles and express multiple loyalties in the same
situation, such as patient advocate and gatekeeper to health care resources. These
different roles can create ethical conflicts. Therefore, we ask that health care delivery
systems be constructed in such a way as to reduce the occasions when providers must play
conflicting roles, and to clarify to the extent possible which roles should dominate in
which situations. Patients have a right to know if a physician is playing a gatekeeper
role. Whenever a physician or other health care professional must play such a role,
patients should be fully informed about the implications of that dual role for the
physician's decision-making process and degree of discretion. If possible, patients should
have the option to choose an alternative mode of care or insurance system in which the
physician is not required to play that role. Education of all health care providers should include instruction in the values and
requirements of the multiple roles that health care providers must play. Providers should
be made aware of the potential for ethical conflicts and be trained to address them. They
should make it clear to all parties concerned the patients, the institutions they
represent, and themselves that, at least with respect to certain decisions, they are
playing multiple roles and have multiple loyalties. Some of the difficult policy goals broader coverage, wider availability of basic health
care, and greater cost-effectiveness could be more readily achieved if a wider range of
health care practitioners were utilized better. Specialized providers, such as midwives,
advanced practice nurses, or physical therapists can and should play important roles in
providing basic health care services. The high level of training required to become a
physician in this country is not necessary for providing many necessary and basic health
care services. While such services should be provided only under the direction of fully
licensed practitioners, there may be many unnecessary institutional barriers such as rules
about reimbursement, state professional practice acts, and outdated prejudices and gender
discrimination, that are contributing to underutilization and unnecessarily low status of
health care providers who are not physicians. It is important, therefore, that such
potential institutional barriers and prejudices be examined to determine if system-wide
reforms are called for. As the current system of delivering and financing health care is transformed,
policymakers should make certain that adequate provision is made for the support and
funding of research and teaching institutions, as well as for technology assessments,
clinical trials, and especially, "outcomes" research conducted in the field.
Outcomes research assesses the link between medical care and outcomes in the context of
the everyday practice of medicine rather than under controlled conditions. It can also be
used to provide information about which providers or systems of health care deliver a
better quality of health care than others. Outcomes research will be a centrally important
instrument for assessing changes in the health care system, whether these are initiated by
the government or by private institutions. The long-term investment needed to sustain the
great work of fundamental medical and biological research and to improve the quality of
medicine both in our country and in the world at large should not be diminished. It
should, however, be carefully assessed in ways that respect its character as free and
disciplined inquiry. HMO's, and other managed care groups should make sure that every patient who enters the
system has a primary care physician, nurse practitioner, or physician's assistant who
provides each patient with a human contact, someone whose responsibility it is to see that
care for that patient is integrated, and to serve as that patient's special advocate
within the system. Schools of the health professions should stress the therapeutic importance of a focus
on patients as whole persons and accordingly include some sensitivity training as well as
training in communications skills for physicians, nurses, and other providers. The
training of physicians and other practitioners should also teach them how to engage
patients and/or their guardians in discussions about their prognosis, and their
expectations and values regarding their quality of life. Such discussions could then
assist the practitioners in making responsible decisions about highly intrusive therapies
or "heroic" measures to extend life.
Woodstock Theological Center
Seminar in Business Ethics
Printed in the United States of America
All rights reserved
Ethical considerations in the business aspects of health care/
Woodstock Theological Center Seminar in Business Ethics.
p. cm.
1. Medical care--Cost control--Moral and ethical aspects.
2. Managed care plans (Medical care)--moral and ethical aspects.
3. Health care rationing--Moral and ethical aspects.
4. Medical ethics--Standards. I. Woodstock Theological Center
II. Title
RA410.5.S36 1995
174'.26--dc20
ISBN 0-87840-587-9 95-5133
TABLE OF CONTENTS
Participants
Ms. Jodie Allen
Editor
Outlook
The Washington Post Mr. J. J. Barry
President
International Brotherhood of Electrical Workers
Virginia Betts, J.D., R.N.
President
American Nurses Association Dr. Margaret M. Blair, rapporteur
Economic Studies Program
The Brookings Institution
Rev. William J. Byron, S.J.
Director
Center for the Advanced Study of Ethics
Georgetown University Rev. James L. Connor, S.J.
Director
Woodstock Theological Center
Martin F. Connor, Esq.
Chairman
Stateside Associates, Inc. Mr. John E. Curley, Jr.
President
The Catholic Health Association
Mr. John E. Curley, Jr.
President
The Catholic Health Association Mr. John J. Curry
Executive Director
American College of Radiology
Professor Norman Daniels
Professor of Philosophy
Tufts UniversityDr. Richard J. Davidson
President
American Hospital Association
Catherine DeAngelis, M.D.
Vice Dean for Academic Affairs
The Johns Hopkins School of Medicine Mr. Horace B. Deets
Executive Director
American Association of Retired Persons
Richard P. Delaney, M.D.
Private Practice
Silver Spring, MD Robert Dickler, M.D.
Vice President
Association of American Medical Colleges
Leah J. Dickstein, M.D.
Associate Dean
Faculty and Student Advocacy School of Medicine
University of Louisville Dr. Thomas C. Dolan
President
American College of Healthcare Executives
Sr. Rosemary Donley, S.C.
Executive Vice President
The Catholic University of AmericaJohn M. Eisenberg, M.D.
Chairman/Physician in Chief
Medical Center
Georgetown University
Mary Jane England, M.D.
President
Washington Business Group on Health Professor Alain C. Enthoven
Marriner S. Eccles Professor of Public and Private Management
Stanford University
Charles H. Epps, M.D.
Dean
Medical School
Howard University Rev. John D. Golenski, S.J.
President
Bioethics Consultation Corporation, Inc.
Hon. Willis Gradison, Jr.
President
Health Insurance Association of America Professor Ronald M. Green
Director
Institute for the Study of Applied and Professional Ethics
Dartmouth College
John Collins Harvey, M.D.
Senior Research Scholar
Center for Clinical Bioethics
Georgetown University James C. Haughton, M.D.
Senior Health Services
Policy Advisor
Department of Health Services
Los Angeles County
Hon. Constance Horner
Guest Scholar
The Brookings Institution Rev. John P. Langan, S.J.
Senior Fellow
Woodstock Theological Center
Rose Kennedy Professor of Ethics
Georgetown University
Willis C. Maddrey, M.D.
Southwestern Medical Center
University of Texas at Dallas Professor William F. May
Cary M. Maguire
Professor of Ethics
Southern Methodist University
Gen. Edward C. Meyer
CILLUFFO Associates Dennis S. O'Leary, M.D.
President
Joint Commission on Accreditation of Health Care Organizations
Hon. Henry Owen
Consultants International Group, Inc. Edmund D. Pellegrino, M.D.
Director
Center for Clinical Bioethics
Georgetown University
Mr. Robert P. Pfotenhauer
President and CEO
Pharmacy Direct Network Mr. Charles O. Rossotti
Chairman and CEO
American Management
Systems, Inc.
Mr. Carl J. Schramm
President
Time Insurance Company Kevin A. Schulman, M.D.
Medical Director
Clinical Economic Research Unit
Medical Center
Georgetown University
Mr. Patrick J. Scollard
Executive Director and COO
St. Francis Hospital
Roslyn, N.Y. Ralph A. Straffon, M.D.
Former President
American College of Surgeons Cleveland Clinic Foundation
James S. Todd, M.D.
Executive Vice President
American Medical Association Mr. Bernard R. Tresnowski
CEO and President
Blue Cross/Blue Shield Association
Dr. Joshua M. Wiener
Economic Studies Program
The Brookings Institution Rev. Kevin W. Wildes, S.J.
Assistant Professor
Philosophy Department
Georgetown University FOREWORD
Director
Woodstock Theological Center
March 15, 1995 SECTION I
THE CHALLENGE Third-party payers
Managed care groups
Rules, records, and reporting
Technology and costs
Aging and costs
Needs or choices
Marketing practices
Large health care systems
"Needs" as "rights"
Litigation
SECTION II
ETHICAL FRAMEWORK A. Compassion and Respect for Human Dignity
B. Commitment to Professional Competence
C. Commitment to a Spirit of Service
D. Honesty
E. Confidentiality
F. Good Stewardship and Careful Administration
SECTION III
PERSONAL DECISIONS IN INDIVIDUAL CASES A. When Resources Are Inadequate to Meet All Needs
1. Short-term Crises
2. Constraints on Capacity to Provide Uncompensated or Undercompensated Care
B. When Providers Own or Profit from Patient Utilization of Specific Resources
1. In the Fee-for-Service Context
a. Out-of-office ancillary services
b. In-office services that are integral to the professional's practice
2. In the Prepaid or Capitated Payment Context
C. When Rules and Regulations Conflict with Professional Judgment
D. When Truthfulness May Be in Conflict with Patient Confidentiality
E. When Patients' Own Behavior Contributes Significantly to Their Problems
F. Where New Technologies Are Emerging Rapidly
1. New Technologies and Competence
2. New Technologies and Stewardship
SECTION IV
CHECK POINTS
SECTION V
CONCLUSION APPENDIX
A REQUEST FOR INSTITUTIONAL ARRANGEMENTS THAT SUPPORT ETHICAL BEHAVIOR A. Decent Minimum Care for All
B. Restraint and Equitable Allocation of Finite Resources
C. Design of Health Care Financing Systems
D. Information about Budget Constraints
E. Information about Peer Performance
F. Coping with Demands of Multiple Roles
G. Validating Roles for a Wider Variety of Providers
H. Adequate Funding for Research
I. Attention to the Needs of "Whole Persons"
See also: