Ethical issues and the electronic health record

Ethical issues related to electronic health records (EHRs) confront health personnel. Electronic health records create conflict among several ethical principals. Electronic health records may represent beneficence because they are alleged to increase access to health care, improve the quality of care and health, and decrease costs. Research, however, has not consistently demonstrated access for disadvantaged persons, the accuracy of EHRs, their positive effects on productivity, nor decreased costs. Should beneficence be universally acknowledged, conflicts exist with other ethical principles. Autonomy is jeopardized when patients' health data are shared or linked without the patients' knowledge. Fidelity is breached by the exposure of thousands of patients' health data through mistakes or theft. Lack of confidence in the security of health data may induce patients to conceal sensitive information. As a consequence, their treatment may be compromised. Justice is breached when persons, because of their socioeconomic class or age, do not have equal access to health information resources and public health services. Health personnel, leaders, and policy makers should discuss the ethical implications of EHRs before the occurrence of conflicts among the ethical principles. Recommendations to guide health personnel, leaders, and policy makers are provided.     

Exploring ethical terrain in public health.

Public health is rife with ethical challenges. Ethical principles and values are intrinsic to public health decision making, although they are generally not identified explicitly. One purpose of this article is to discuss public health goals as an ethical/value concern with attention to values that do and should underlie health care in the United States. A second purpose is to introduce frameworks for public health decision making that incorporate ethical considerations into community and health promotion perspectives of public health decision makers. Public health policy makers and providers are urged to explore ethical/value dimensions of the health care system and to use the ethical frameworks in their decision making, expanding the more individualistic perspective of traditional bioethics.     

Ethics and health planning: implications for education

Over the past decade in this country, there has been a rekindling of interest in the ethical questions of public policy. Moreover, the concern for ethical issues is nowhere more evident than in the field of health care. However, the ethical problems of health planning, particularly as practiced at the regional level, have scarcely received attention. This article explores the ethical dimensions of health planning and argues that health planners have not been adequately prepared, neither through their education nor through socialization in the profession, to deal with the complex ethical issues facing them. However, health planning theory can be enriched and practice improved if the ethical issues are confronted. Health planning is viewed as one means of achieving social justice because the benefits and burdens associated with health care are distributed to the members of society by the decisions made in the health planning process. However, planning decisions are not meekly accepted by the persons affected. More often than not, health planning decisions produce substantial political controversy, which is due, in part, to the planning methods commonly used. The synoptic or comprehensive planning approach avoids ethical questions by ignoring them. The incremental planning approach deals with them but only in terms of political process. Neither of these approaches is particularly useful for resolving health planning's ethical questions. The implications of these findings for education in health planning are discussed. The merits of the case study as a means of ethical education are presented.     

Ethical analysis to improve decision-making on health technologies

Health technology assessment (HTA) is the multidisciplinary study of the implications of the development, diffusion and use of health technologies. It supports health-policy decisions by providing a joint knowledge base for decision-makers. To increase its policy relevance, HTA tries to extend beyond effectiveness and costs to also considering the social, organizational and ethical implications of technologies. However, a commonly accepted method for analysing the ethical aspects of health technologies is lacking. This paper describes a model for ethical analysis of health technology that is easy and flexible to use in different organizational settings and cultures. The model is part of the EUnetHTA project, which focuses on the transferability of HTAs between countries. The EUnetHTA ethics model is based on the insight that the whole HTA process is value laden. It is not sufficient to only analyse the ethical consequences of a technology, but also the ethical issues of the whole HTA process must be considered. Selection of assessment topics, methods and outcomes is essentially a value-laden decision. Health technologies may challenge moral or cultural values and beliefs, and their implementation may also have significant impact on people other than the patient. These are essential considerations for health policy. The ethics model is structured around key ethical questions rather than philosophical theories, to be applicable to different cultures and usable by non-philosophers. Integrating ethical considerations into HTA can improve the relevance of technology assessments for health care and health policy in both developed and developing countries.     

Managing the gap between demand and publicly affordable health care in an ethical way

A major health policy challenge of the 1990s is to manage thegap between the demand for health care and our ability to payfor care and to do so in an ethical way. This paper describesEuropean responses to the gap, which have been to do nothing,to do more with the same or less resources, to do more withmore resources, to change behaviour and attitudes and to definehealth needs more narrowly. These responses have not reducedthe gap and cannot prevent it from widening in the future. Rationingand prioritizing are other responses, which will have an increasinglyimportant role. This paper proposes that the survival of publichealth care systems depends on recognizing and ‘managing’the gaps and doing so in an ethical way. Conventional responseshave ethical problems equal to or more serious than those involvedin rationing and prioritizing. The paper proposes that rationingand prioritizing must become more central methods for managingthe gap between resources and demand in the future, but thatsuch approaches will need to be more explicit and ethical ifthey are to gain public support.     

Advanced training in biomedical ethics: a curriculum in clinical specialty programmes

Summary. Medical ethics play an essential role in the practice of medicine, in the care of individual patients, in the allocation of health care resources, and in the formulation of health care policy. A specific body of knowledge, ‘biomedical ethics’, has developed which applies ethical theory to biomedical practice. This has provided doctors with tools systematically to integrate rational ethical analysis into clinical decision-making. Training in the discipline of biomedical ethics is now required for all doctors in Canada. The goals, content areas, learning objectives, and learning methods considered appropriate for advanced training in this field for medical specialists are provided in this paper. Six topic areas are discussed: introduction to ethical theory, clinical ethics, professional ethics, ethics of human experimentation, ethics of health policy, and independent study. Ways this curriculum could be organized and evaluated are also offered.     

Clinical practice, ethics and economics: the physician at the crossroads

In recent years health services have faced the challenge of increasingly complex services and rising costs, thus the consideration of costs is a key factor in health policy decisions. The introduction of an economic perspective has sometimes been viewed as conflicting with the ethics of the health care system, especially at the physician-patient level. this article explores the important role of the physician from the ethical and economic perspective in the distribution and allocation of services. An understanding of economic and ethical principles reveals that these two perspectives are compatible with good clinical practice: more efficient health care implies better care for the individual patient and makes it possible to increase the resources available to improve care for the population as a whole. Thus, being efficient is an ethical objective. The selective elimination of ineffective services would free resources to care for those who need effective diagnostic or therapeutic procedures. This requires a better understanding of the determinants and outcomes of clinical practice, physician motivation, the appropriate design and application of incentives, and the best use of limited resources. The physician can play a key role in increasing the efficiency, equity, and quality of the health system without restricting the provision of effective services.     

Cost offset effect strategies for the provision of mental health care services

This analysis examines what is currently known about the financial efficacy of mental health services in relation to the cost offset effect in health care. Moreover, it suggests that the provision of mental health services should be intertwined with cost offset strategies in regard to its practice, research, and promotion. In doing so, policy decisions and ethical practices of care concerning mental health care delivery may be shaped within an adequate cost structure.     

Instructions to Authors

The Milbank Quarterly publishes scholarly papers that enhance understanding of significant research questions and policy issues pertaining to health and health care. It presents original research, syntheses, policy analysis, and commentary from academicians, clinicians, and policymakers. Papers may come from any discipline, but should seek to communicate beyond the author's own discipline. Topics theQuarterly addresses include (but are not limited to) the impact of social factors and policy on health, disease prevention, allocation of health resources, legal and ethical issues in health policy, and the organization and financing of health care. All papers submitted are subject to blind peer review regarding scholarly soundness and substantive significance.     

Ethics and financing: overview of the U.S. health care system

An overview of the financing decisions that occurred with the U.S. health system during the past five decades was presented in relation to the ethical issues which gave rise to and resulted from those financing decisions. This health system evolved from decision-making grounded in altruism through increasing the access and supply of resources to a position of caution and financial prudence. Recently the decision-making became grounded in pragmatism with the realization that attempts to provide everyone with all possible health services on demand cannot be achieved. Financing decision have resulted in a health care system based on acute care and sophisticated technology but with too many hospital beds and physicians, both geographically maldistributed. Since this acute care system has been successful in preventing premature deaths, our population now lives longer and develops chronic illnesses which require different interventions; the system has neglected to focus on prevention and adequate care for long-term diseases. It has created a growing population of uninsured who are unable to afford health care when illness occurs. Alternative strategies were discussed at three levels of the health system. At the overall system level, the following was proposed: consistent application of ethical principles most appropriate to allocation decisions and the creation of health policy which encompasses chronic care and disease prevention components. At the organizational level, health administrators and local community leaders must cooperatively address local health issues; medical education should focus on long-term care and disease prevention; and medical practice should reduce variation in treatment patterns. At the population level, healthy lifestyles must be encouraged in addition to the development of alternative reimbursement plans to maximize access to health care. Davis and Rowland (1990:298) have stated that our nation's image is strained" ... as a just and humane society when significant portions of the population endure avoidable pain, suffering and even death because of an inability to pay for health." These are turbulent times in health care but addressing the ethical issues at many levels may lead to successful alternatives and ultimately to a workable health strategy for this country.     

A framework for applying ethical theory to public health practice.

Like most other public health agencies, the Georgia Department of Human Resources, Division of Public Health (DPH) has encountered a growing number of questions and conflicts with ethical implications. To address these and other questions, DPH started to develop a framework, in January 1985, specifically related to solving problems, setting priorities, and developing policy that adds an ethical perspective. DPH must deal with issues and conflicts that transcend the traditional model of medical care: with the new economic reality, programs must continue with less resources; medical technology is now raising questions, but not necesarily answers, related to life and death; and the rights and responsibilities of individuals and institutions are not clearly defined. In this context, DPH has started to examine ethical considerations with respect to the individual and the community. An interface exists between ethical theory and health care. Over the years, however, this relationship has assumed different manifestations, ranging from the formation of precise conduct codes for health care professionals to the establishment of review boards that examine specific morally questionable procedures. DPH's purpose in applying ethical theory to its health care practices is not to develop an inflexible code nor a committee to review isolated cases of moral conflict. The purpose is to use ethical theory as a form of vision for the remainder of the 1980s and beyond.     

Problematising the ethics of organ donation after circulatory death in the UK

This commentary addresses the ethics of controlled organ donation after circulatory death (DCD) in the UK, a practice which has recently been revived as part of attempts to increase rates of organ donation. Despite being linked to growth in donor rates, bioethics and clinical scholars have drawn attention to the ethical issues which DCD poses for health professionals, particularly around the requirement to alter the end-of-life care of potential donors. In this commentary, the UK policy response to the ethics of DCD is examined by drawing on Foucault’s problematisation approach. This analyses the broader contexts within which the policy version of ethics for DCD has been created, and examines the potential implications of this form of ethics for the work of health professionals. It is argued that the policy version of ethics for DCD has a specific normalising role, which acts as an integral part of the efficiency drive by transplant medicine to optimise the potential for donation. In turn, this form of ethics is premised upon providing the right tools for health professionals to make ethical decisions around DCD. In so doing, it fails to account for the everyday practices of health professionals involved in end-of-life care. In conclusion, the commentary advocates bringing the social science perspective into debates on DCD, to ensure that the terms and practice of this technology, and its policies, are adequately problematised.     

试论制度安排与健康公平的实现

健康公平是人类共同追求的目标,但由于经济、社会和文化等因素又造成了健康的极大不公平。遗憾的是,我国卫生改革从一开始就缺乏伦理基准,医疗服务过度市场化倾向、政府责任不到位和伦理缺席已将卫生改革引向功利主义的死胡同,使得卫生改革背离了公正目标。如何通过有效的公共政策和制度安排促进健康公平,这是全社会关心的问题。在今后的深化改革中,必须加大政府的投入,围绕公平目标,建立覆盖全民的医疗保障体制。     

Ethical requirements for occupational health research--compliance arrangements for a single company in relation to a recent major nuclear industry study.

The media coverage given to occupational health studies in the field of ionizing radiation has, on occasion, been the cause of very real distress to radiation workers and their families. In response to this situation the Chief Medical Officers of the major UK nuclear companies developed an ethical policy for future involvement in research, based on the duty of care which researchers owe to a key customer of such studies: the worker. The policy consists of four principal elements: medical confidentiality; worker information; worker consent and the guarantee of the availability to the workers of pre-publication knowledge of the results. The policy issued in 1991/92 has achieved growing acceptance among researchers and medical journals, though the medical officers involved have been aware of some scepticism, particularly in relation to the practicalities of the dissemination of pre-publication information. The Record Linkage Study published in November 1997 marked a major piece of research work involving data from 120,000 radiation workers that had been carried out since the development of the policy. This paper reports on the successful compliance arrangements to meet the ethical requirements of that study within a single UK nuclear company, and is published to demonstrate that with commitment from researchers, the journal and occupational health staff such ethical requirements, and particularly the need for pre-publication information can be met in full.     

Health care rationing: can we afford to ignore euthanasia?

Explicit rationing decisions are being made to encompass a wide range of health care issues. Voluntary euthanasia has largely been excluded from this debate due to, in my view, the emotive nature of the issue. Euthanasia is an issue in which economists have been largely excluded and in which ethicists and philosophers dominate. It is the purpose of this paper to review the economic and ethical literature on euthanasia and to discuss their compatibility within the debate on euthanasia. The potential cost savings by the use of advance directives, do-not-resuscitate orders, and futile care withdrawal are then reviewed, as are the potential cost savings created by hospice care. As a conclusion, the ethical and economic arguments are then balanced to assess their compatibility. It is the contention of this paper that reducing medical care costs near the end of life should not be a taboo subject, and that rationing decisions could focus on an exploration of this area and the approaches to it, which are ethically justifiable and economically worthwhile. The introduction of a policy of voluntary euthanasia could have a large impact on the rationing of health care resources whilst also promoting patient choice and an arena for a more dignified death.     

Involuntary stabilization care of youth who overdose: a call for evidence- and ethics-informed substance use policy

As is the case across Canada, the province of British Columbia is in the midst of an opioid overdose crisis. In response to the devastating impacts of this crisis on youth (under 19 years of age), the provincial government is considering amending the Mental Health Act to allow for involuntary, hospital-based stabilization care of youth following an overdose. This policy change represents one concrete action that the provincial government is exploring in response to public advocacy for enhanced supports for youth who overdose. At this juncture, however, we are concerned that stabilization care requires further interrogation in the context of key, interrelated public health and ethical dimensions pertaining to this legislation. In this commentary, we describe three key areas for public health deliberation: (1) the evidence underpinning stabilization care, (2) ethical considerations, and (3) the potential for unintended and unevenly distributed consequences. We then offer ways forward to guide and provide opportunities for a more equitable public health response to the overdose crisis and its impacts on youth. In doing so, we emphasize the need for meaningful engagement of youth as key stakeholders in the development of evidence- and ethics-informed substance use care and policy interventions.     

Lithuanian health care in transitional state: ethical problems

Background  

Throughout the economic and political reforms in post-communist countries, significant changes have also occurred in public morality. One of the tasks of the Lithuanian health policy is to create mechanisms for strengthening the significance of ethical considerations in the decision-making processes concerning health care of individuals and groups of individuals, as well as considering the positions of physicians and the health care system itself in a general way. Thus, health care ethics could be analyzed at two levels: the micro level (the ethics of doctor-patient relationships) and the macro level (the ethics of health policy-making, which can be realized by applying the principles of equal access, reasonable quality, affordable care and shared responsibilities). To date, the first level remains dominant, but the need arises for our attention to refocus now from the micro level to the patterns of managing and delivering care, managing the health care resources, and conducting business practices.     

An ethical justification for the Chronic Care Model (CCM)

Background:  Chronic diseases are major causes of morbidity and mortality in developed countries. Their effects can be mitigated by high quality evidence-based care, but this is not the norm in most systems. The Chronic Care Model (CCM) is an evidence-based policy response to this practice gap, which uses multiple strategies to promote the quality of chronic care.
Objective:  To review CCM with an ethical lens.
Methods:  We reviewed the published empirical and non-empirical articles of CCM to analyse the ethical underpinnings of this model.
Results and conclusions:  We argue that its principal ethical value lies in the institutional cooperation it builds between the stakeholders involved in health care services. First, we briefly describe CCM and argue that the pathways through which it aims to improve patients' health outcomes are not made explicit. Second, we argue that the potential of CCM to be more beneficent, compared with traditional health care systems, depends on its capacity to promote mutual trust between health care providers and patients. There is no evidence to date that the implementation of CCM enhances mutual trust between health care professionals and patients. Third, we argue that CCM seeks to enhance human agency, allowing increased expression of individual autonomy and increased respect for individuals thereby expanding human freedom and avoiding social discrimination. However, we review the communication patterns that characterize the model of doctor–patient relationship promoted by this model and argue that these communication patterns raise ethical concerns that may prevent the model from reaching its expected outcomes.     

Cross-border mobility of health professionals: contesting patients' right to health

Cross-border labour mobility in the health sector is portrayed as both an opportunity for health professionals immigrating to developed countries, and as a challenge for patients remaining in low-income countries with restricted access to health care provision. In policy debate, this problem is articulated as the opposition between, ‘the right to freedom of movement’ and ‘the right to health’. The underlying layers of this dilemma expose competing institutional interests for source and destination countries, international organisations, private recruitment agencies, trade unions and professional organisations. To resolve some of these tensions, a ‘soft law’ regulation (ethical recruitment policy) was adopted in the UK in the early 2000s.This article argues that this ethical recruitment policy produces an ambivalent effect. The qualitative content analysis refers to documents produced by international organisations, government bodies, professional organisations and trade unions in the UK and source countries. We found that ethical recruitment on the one hand proposes a practical mechanism to the realisation of the right to health in source countries, through encouraging employers’ behaviour in accordance with ethical principles in international recruitment. On the other hand, this policy protects the reputation of institutional stakeholders changing rhetoric around international recruitment rather than the practice. The findings of this study contribute to a broader discussion of the international norms diffusion and the ambivalent role of ‘soft law’ in their implementation.     

Family planning in the balance

Family planning has long been acknowledged as an effective public health intervention. In recent years, however, family planning has come under increased scrutiny from conservative politicians and constituents. National US policies instituted since 2001 are resulting in cutbacks in family planning programs worldwide. In the long run, these conservative initiatives may set back several decades of progress in reproductive health and reproductive rights. In promoting an ideologically driven approach to sexual and reproductive health, the recent policy developments threaten to subvert ethical standards of medical care and the principle of evidence-based policy.