The ethics of medicine vs. the ethos of Wall Street (Part II).

This is the second article in a two-part series by Contributing Editor Stephen J. Hage. In Part I, Mr. Hage examined how the business of health care delivery and financing interfaces with the practice of medicine. He argued that the result is often a struggle between the ethics of providing care versus the ethos of doing business. In Part II, he traces the role business has played and responsibility it must assume for shaping our contemporary health care system. He ends by offering specific recommendations for dealing with the ethics versus ethos dilemma.     

Power: a changing commodity

"Rapid and tumultuous change in health care as well as business has precipitated a power shift," declares Mr. Hage in this candid discussion of a quality that is both abstract and concrete. Centralized power is no longer the order of the day; in fact, the new stance supports pushing power down into organizations where it can be better used by those closer to the action. The author maintains that effective participants in this new model will learn to share power and respect knowledge as the only tool that wields it.     

A lesson in legal theft

Yes, Mr. Hage admits the cost for health care is high--it's now 11% of the GNP. However, "society reaps real and tangible benefits from its availability," defends the author. This article questions a government which on the one hand denies appropriate care to many of those who need it most through health care cutbacks while on the other hand accepts a $500 billion bill for the S&L bailout.     

Ethical issues in health care institutions. Lesson Four: Allocation of medical resources

Health care rationing is the subject of the fourth lesson in a five-part WMU/AHRA magazine course on ethics. Since not every citizen in our country is guaranteed the right to basic health care, there exists a rationing system in which health care is allocated on the basis of ability to pay and need, asserts Dr. Hartline. Ethical problems abound within this system. This article addresses the issues and proposes possible remedies.     

Food for thought. Dueling gorillas.

HMOs, the "new darlings" of big business healthcare, are the latest to feel the sting of government's cost cutting schemes. Mr. Hage writes. But, unlike not-for-profit hospitals, HMOs have the knowledge and the prerogative to simply walk off the Medicare tightrope and opt out of the game.     

Bioethical conflicts between Muslim patients and German physicians and the principles of biomedical ethics

In the age of globalisation, more and more people who are members of different religions and cultures live in the same society. This situation tends to create many conflicts in different areas of life and not least in the health care system, a fact which raises a number of bioethical issues. The cultural and religious differences between patient and physician can be a cause of bioethical conflicts and therefore represent a challenge for biomedical ethics. The confrontation between Turkish Muslin patients and the German health care system is a convenient example of this situation. The Muslim Turks came to Germany 40 years ago as industrial workers. Their value system had been shaped by traditional and Islamic parameters in Turkey. With this value system, they now found themselves in the German modern health care system. In many fields of modern medicine there are areas of potential conflict of values, where a Muslin patient will argue differently from a secular or Christian person. In an ethical conflict between two individuals who are members of different cultures, it is necessary to make sure that the ethical concept which is to be used for resolving the problem is relevant. In this particular case, both the Islamic legal responses (fatwa) and the classical theories of biomedical ethics are often insufficient. This paper tries to give a brief outline of these bioethical conflicts and discuss these conflicts with regard to the principle of respect for autonomy in the concept of "principilism," as introduced by T.L. Beauchamp and J.F. Childress. The central question is whether this bioethical concept is able to analyse and to help solve the kinds of ethical conflicts which involve transcultural dimensions. This question is discussed with some consideration of the ongoing debate about universalism versus relativism in biomedical ethics.     

What'll ya have?

Before choosing a plan to finance healthcare, we must decide whether we consider ourselves subscribers or patients, Mr. Hage says. And we each must decide how healthy we are, because that determines how much we're willing to pay for medical coverage, he adds. In the article, Mr. Hage describes two proposed financing approaches and tells why he thinks both of them miss the mark.     

Military nursing and diagnosis-related groups: using the past to benefit our future

To contain the escalating cost of health care, a prospective payment system is being introduced into the military. The authors propose a proactive approach to this change in health care financing by evaluating the experiences of nurses to a similar change in the civilian sector. These approaches are presented as nine interrelated lessons: responding optimistically; shifting into a business mode; valuing clinical nursing experts; understanding the implications for documentation; moving to decentralized management; changing outpatient care delivery; considering the effects on job satisfaction; evaluating the relationship between costs and nursing resource consumption; and basing nursing practice in science.     

Nikolay Terentevich Potyomkin (on the occasion of 90th anniversary of the birth)

The article is confined to the 90th anniversary of the birth of famous organizer of medical arrangement of Russian Navy, participant of the Great Patriotic War, Honored Doctor of RSFSR, major-general of Medical Service Nikolay Terentyevich Potyomkin (1.05.1922-9.11.1994). He leaded Medical Service of Russian Navy almost 10 years, from January 1976 till November 1985, and made the contribution to development of organization of medical arrangement of oceanic nuclear missile Navy of our country. N. T. Potyomkin made the contribution to development of organization of medical arrangement of the ships and shore objects of Russian Navy. He paid attention to improvement of delivery of health care to complement, drawing active service in the seven seas.     

Basic care, bodily knowledge and feminist ethics

Within medical schools and within research concerning the ethical questions of health care, basic care and its allied participants have not been stressed enough. The aim of this paper is to emphasise the practice of basic care and some moral problems in connection to this practice. Basic care is the care-provider's providing assistance for patients with bodily dysfunction. The relationships between patient and care-provider in basic care have many substantial similarities with other close social relationships. Thus, the interactive relationships in basic care are an important matter of public concern. Seen from an ethical perspective, its significance due to the welfare-aspects of society is obvious. Patients and professionals in basic care have together a unique knowledge about the meaning of being. Ethics is much more than following theories, rules, and principles and this article presents an alternative to the dominant approaches of health care ethics.     

How do training, education, and experience affect quality in radiology?

The quality of care is attracting increasing attention from payers, regulators, and consumers. The assumption that training, education, and experience are major determinants of quality and safety permeates the health care delivery system. However, the relationship between quality and training, education, and experience is neither straightforward nor well documented, particularly for the practice of radiology. A recent Institute of Medicine report questioned the effectiveness of the existing system for the education and training of health care professionals. In this article, “quality” in radiology is defined, and evidence for a relationship between quality care and experience and traditional continuing medical education is reviewed. Alternative approaches to education and training, with an emphasis on systems rather than individuals, are elucidated. The nature of radiologist training, education, and experience should be reexamined and adjusted to meet the changing demands of the health care delivery system.     

Productivity and quality patient care

Because of the need to control rising U.S. health care costs, managers today not only must focus on their staff and patients, but also on the business aspects of radiology, such as increasing productivity. Balancing productivity with quality patient care is not an easy task--it requires changes by the entire radiology team, including managers, technologists and radiologists. After completing this article, the reader should be able to: Discuss why health care costs continue to rise. Define productivity, how it can be measured and why it must be measured in today's health care settings. Recognize how patient satisfaction contributes to a health care organization's bottom line. Understand the health care team's role in simultaneously increasing productivity and patient satisfaction.     

What's wrong with this picture?

According to Mr. Hage, when the government tries to measure economic output, "the 1930's mentality sticks like bubble gum to the sole of a shoe." He is alarmed that the current debate about healthcare reform is based on economic data derived from antiquated methods of analysis and that we are "rocketing into the 21st century with our eyes firmly fixed on the rear-view mirror."     

The military physician assistant.

The origin of the physician assistant began with medically trained military personnel. Now, 25 years later, the military has over 1,100 physician assistants working in all aspects of health care delivery. This article examines the historical perspective and discusses current and emerging issues for the utilization of military physician assistants.     

Contracting out military health care

The military health care system is currently facing a critical provider supply versus patient demand imbalance. Contracting out health care through the Civilian Health and Medical Program of the Uniformed Services and the Primary Medical Care for the Uniformed Services programs is one approach that Army Medical Department leaders have taken to correct the problem. This article critically analyzes the success of this approach using data from an Army hospital in the eastern United States. The article concludes with three suggestions aimed at improving the current situation.     

Health promotion/disease prevention: implications for radiologic technology

Various societal changes, including a new health awareness and increased federal involvement in health care, are altering the nature of health care delivery. This article discusses the nature of the national initiative in health promotion/disease prevention and attempts to give a meaningful role for radiologic technologists in the HP/DP movement.     

Prevention of violence in prison – The role of health care professionals

The World Health Organization (WHO) classifies violence prevention as a public health priority. In custodial settings, where violence is problematic, administrators and custodial officials are usually tasked with the duty of addressing this complicated issue-leaving health care professionals largely out of a discussion and problem-solving process that should ideally be multidisciplinary in approach.Health care professionals who care for prisoners are in a unique position to help identify and prevent violence, given their knowledge about health and violence, and because of the impartial position they must sustain in the prison environment in upholding professional ethics. Thus, health care professionals working in prisons should be charged with leading violence prevention efforts in custodial settings.In addition to screening for violence and detecting violent events upon prison admission, health care professionals in prison must work towards uniform in-house procedures for longitudinal and systemized medical recording/documentation of violence. These efforts will benefit the future planning, implementation, and evaluation of focused strategies for violence prevention in prisoner populations.     

Challenges of including dietitians, nurses, occupational therapists, and pharmacists in the Federal Credentialing Program

Credentialing and recredentialing of federal health care providers involves hundreds of hours of labor and associated costs. This article presents the history of credentialing and efforts to expand the Federal Credentialing Program to include dietitians, nurses, occupational therapists, and pharmacists and discusses barriers to this possible expansion. Representatives from federal and civilian health care service delivery agencies and credentialing and licensure bodies will gather to establish common credentialing information for these professions. Discussing barriers to these efforts will help to ensure success. In addition, a more efficient and streamlined system could easily be adopted by the civilian sector for these professions.     

The Balanced Scorecard versus Total Quality Management: which is better for your organization?

Today's health care organizations must deal with managed care, government oversight, aging baby boomers, new technologies, and increasing pharmaceutical prices. It is imperative that health care organizations adopt some form of business strategy to manage the vast amount of information available. Two of the more popular strategies among health care organizations are the Balanced Scorecard and Total Quality Management. Which one of the strategies is best for an organization? The answer to this question is that it depends on the organization. This article provides the fundamentals of each strategy and contrasts their strengths and weaknesses, so that interested organizations can make informed decisions regarding the best strategy for each organization.     

Addressing ethical issues in geriatrics and long-term care: ethics education at the Baycrest Centre for Geriatric Care

An innovative program in ethics education exists at Baycrest Centre for Geriatric Care. This program can serve as a helpful model for long-term care and geriatric care facilities seeking to implement formal training programs in bioethics. Various aspects of the ethics education program are examined. In addition to describing the role of the ethics committee and research ethics board, consideration is given to case consultations, ethics rounds, the training of junior physicians and medical students, grand rounds and the planning of conferences and guest lectures. With regard to educational content in bioethics, health law, professional guidelines and the principlist approach of Beauchamp and Childress are used to explore the ethical dimensions of particular cases. Given the clinical context of the educational initiatives, the pedagogical approach is predominately case-based. While the bioethics literature emphasizes the patient-physician relationship, ethics education at Baycrest recognizes the importance of multiple professions. Physicians, nurses, social workers, speech pathologists, nutritionists and other health care providers are involved in ethical deliberation and education.