Ethical guidance in the era of managed care: an analysis of the American College of Healthcare Executives' Code of Ethics

Market competition and the rise of managed care are transforming the healthcare system from a physician-dominated cottage industry into a manager-dominated corporate enterprise. The managed care revolution is also undermining the safe-guards offered by medical ethics and raising serious public concerns. These trends highlight the growing importance of ethical standards for managers. The most comprehensive ethical guidance for health service managers is contained in the American College of Healthcare Executives' (ACHE) Code of Ethics. An analysis of the ACHE Code suggests that it does not adequately address several ethical concerns associated with managed care. The ACHE may wish to develop a supplemental statement regarding ethical issues in managed care. A supplemental statement that provides more specific guidance in the areas of financial incentives to reduce utilization, social mission, consumer/patient information, and the health service manager's responsibility to patients could be extremely valuable in today's complex and rapidly changing environment. More specific ethical guidelines would not ensure individual or organizational compliance. However, they would provide professional standards that could guide decision making and help managers evaluate performance in managed care settings.     

Maximize learning through wellness

By achieving wellness to some degree in all five components of health, the self-concept of the health care employee can be raised. If the worker begins with physical health, this can in turn affect the emotional, mental, social, and spiritual health of the individual. All of these elements of well-being have been shown to have a profound effect on learning abilities and performance levels of the adult. Health care professionals are dealing with life or death decisions on a daily basis. Hopefully, everyone would agree that the health care team should be performing at its peak ability. To do this, each member of the health care team should strive for wellness. The health care facility should promote wellness for its employees first, so they in turn can deliver quality health care services. Keeping current with the constant changes in the health care industry and learning new information is a critical part of that delivery of quality care.     

Ethical issues in health workforce development

Increasing the numbers of health workers and improving their skills requires that countries confront a number of ethical dilemmas. The ethical considerations in answering five important questions on enabling health workers to deal appropriately with the circumstances in which they must work are described. These include the problems of the standards of training and practice required in countries with differing levels of socioeconomic development and different priority diseases; how a society can be assured that health practitioners are properly trained; how a health system can support its workers; diversion of health workers and training institutions; and the teaching of ethical principles to student health workers. The ethics of setting standards for the skills and care provided by traditional health-care practitioners are also discussed.     

The case for a code of ethics in an ambulatory care setting

The health care industry leads others in the development and use of professional codes of ethics. However, ambulatory care facilities continue to operate without coherent ethical guidelines addressing the workplace itself. New diagnostic and treatment capabilities, coupled with economic pressures, have intensified the ethical dilemmas facing the ambulatory care practice. This article argues that office codes of ethics decrease the risk of liability exposure, clarify the expectations of patients and staff, and foster responsible ethical reflection in the workplace. Material for this article was gathered from relevant literature in the areas of business ethics, bioethics, and health care management.     

AMA unveils health care ethics program, toolkit

High-quality health care delivery means upholding high ethical standards. Ethical Force develops performance measures for ethics quality. Toolkit includes questionnaires, surveys, and other forms to assess ethics performance.     

Integrating public health programs and research after the malaria vaccine implementation program (MVIP): Recommendations for next steps

BackgroundIn February 2020, international controversy arose about the ethical acceptability of the WHO Malaria Vaccine Implementation Program (MVIP). Whereas some have argued that this program must be seen as research that is not in line with international ethical standards, notably regarding informed consent and local ethical review, some WHO representatives consider the MVIP as a public health implementation program that need not adhere to these standards.MethodsWe performed a case analysis in light of the 2016 CIOMS International Ethical Guidelines for Health-related Research involving Humans.FindingsWe argue that the MVIP has a substantial research component, and that it is prudent to therefore apply ethical norms for research involving humans, such as the CIOMS guidelines. Accordingly, we agree that the ethical requirements of informed consent and independent ethical review have not been met. In addition, we are concerned that the study might not meet CIOMS’s social value requirement.RecommendationsWe urge WHO to release more details about the process that led to the MVIP program and make the MVIP protocol publicly available. The full protocol should be assessed by the relevant ethics committees, new and already enrolled parents should be informed about the uncertainties under investigation and given a real opportunity to consent or refuse (continued) participation, communities should be engaged, and aspects of MVIP that require alteration in light of ethical review should be altered, if possible. Furthermore, in order to improve good ethical practices, it is necessary to engage in international debate regarding the integration of research and public health programs. Procedurally, vaccine implementation programs that combine both prevention and research should involve the wider international ethics community and ensure participation of the target populations in setting the proper conditions for launching such programs.     

Ethical preferences for the clinical practice of empowerment social work

Social workers in health care and mental health benefit from interventions that integrate principles of contextual social work practice with standards for clinical practice. The authors articulate a conceptual framework for the ethical practice of social work that complements the social justice purpose. The sixteen ethical preferences in this framework are the ethics of care, autonomy, power, change, respect, critical thinking, praxis, discourse, critique, justice, contextual practice, inclusion, anti-oppression, advocacy, collaboration, and politicized practice.     

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.     

The facility audit and review method: evaluating institutional ethics in health care organizations

Auditing processes--such as financial, compliance, and investigative audits-are commonplace in the health care industry. However, an audit to assess institutional ethics in health care facilities is a fairly new concept. The Facility Audit and Review Method is an assessment tool that provides an evaluation scheme to review the organization's policies, procedures, and outcomes using an ethical perspective. This article discusses ethics in the context of health care, the various types of auditing mechanisms used in health care facilities, and how these two--ethics and audits--come together to form the 4-stage Facility Audit and Review Method.     

Implicit and Explicit Clinical Ethics Support in The Netherlands: A Mixed Methods Overview Study

Internationally, the prevalence of clinical ethics support (CES) in health care has increased over the years. Previous research on CES focused primarily on ethics committees and ethics consultation, mostly within the context of hospital care. The purpose of this article is to investigate the prevalence of different kinds of CES in various Dutch health care domains, including hospital care, mental health care, elderly care and care for people with an intellectual disability. A mixed methods design was used including two survey questionnaires, sent to all health care institutions, two focus groups and 17 interviews with managing directors or ethics support staff. The findings demonstrate that the presence of ethics committees is relatively high, especially in hospitals. Moral case deliberation (MCD) is available in about half of all Dutch health care institutions, and in two-thirds of the mental health care institutions. Ethics consultants are not very prominent. A distinction is made between explicit CES forms, in which the ethical dimension of care is structurally and professionally addressed and implicit CES forms, in which ethical issues are handled indirectly and in an organic way. Explicit CES forms often go together with implicit forms of CES. MCD might function as a bridge between the two. We conclude that explicit and implicit CES are both relevant for clinical ethics in health care. We recommend research regarding how to combine them in an appropriate way.     

Health informatics: ethical issues

Ethics is a component of the education of health care mangers and supervisors. Recent advances in the technologies of health informatics present these leader with new ethical challenges. Holding the promise of beneficence, these technologies are purported to increase access, improve quality, and decrease the costs of care. Aspects of these technologies, however, create conflicts with the ethical principles of autonomy, fidelity, and justice. Infoethics is suggested as a means to examine these conflicts. A multipronged solution that incorporates adherence to regulations and standards, promotion of codes of conduct and ethics, and creation of a culture of infoethics is recommended.     

The transfer of patients' ethics information among cooperating institutions: A future function of ethics networks

With increasing use of ethics resources by health care teams, the number of patients transferred from one care setting to another who may have had ethics consultations is rising rapidly. There has been virtually no discussion in the ethics literature and no experience in our community addressing questions concerning the continuity of ethics care and the transfer of ethics information. Our ethics committee faced the following questions during a recent consultation. Should there be continuity of ethics care between institutions? If so, what should be the nature of the communication? How is continuity best accomplished? Do ethics consultants or committees incur additional liability following the transfer of care? Where should the boundaries of confidentiality be drawn? How can existing health care ethics networks facilitate continuity of ethics care? We address these ethical and logistical questions and hope to encourage others to report their views on these issues.     

Ethics and resource allocation: an economist's view

This paper debates some of the issues involved in attempting to apply economic analysis to the health care sector when medical ethics plays such an important part in determining the allocation of resources in that sector. Two distinct ethical positions are highlighted as being fundamental to the understanding of resource allocation in this sector -- deontological and utilitarian theories of ethics. It is argued that medical ethics are often narrowly conceived in that there is a tendency for the individual, rather than society at large, to form the focal point of the production of the service "health care'. Thus medical ethics have been dominated by individualistic ethical coded which do not fully consider questions relating to resource allocation at a social level. It is further argued that the structure of the health care sector augments these "individualistic' ethics. It is also suggested that different actors in the health care sector address questions of resource allocation with respect to different time periods, and that this serves to further enhance the influence of "individualistic' ethical codes in this sector.     

Ethical behaviour in clinical practice: a multidimensional Rasch analysis from a survey of primary health care professionals of Barcelona (Catalonia,Spain)

Purpose

Normative ethics includes ethical behaviour health care professionals should uphold in daily practice. This study assessed the degree to which primary health care (PHC) professionals endorse a set of ethical standards from these norms.

Methods

Health care professionals from an urban area participated in a cross-sectional study. Data were collected using an anonymous, self-administered questionnaire. We examined the level of ethical endorsement of the items and the ethical performance of health care professionals using a Rasch multidimensional model. We analysed differences in ethical performance between groups according to sex, profession and knowledge of ethical norms.

Results

A total of 452 Professionals from 56 PHC centres participated. The level of ethical performance was lower in items related to patient autonomy and respecting patient choices. The item estimate across all dimensions showed that professionals found it most difficult to endorse avoiding interruptions when seeing patients. We found significant differences in two groups: nurses had greater ethical performance than family physicians (p < 0.05), and professionals who reported having effective knowledge of ethical norms had a higher level of ethical performance (p < 0.01).

Conclusions

Paternalistic behaviour persists in PHC. Lesser endorsement of items suggests that patient-centred care and patient autonomy are not fully considered by professionals. Ethical sensitivity could improve if patients are cared for by multidisciplinary teams.     

Ethik versus Ökonomie in Public Health?

In the course of establishing the discourse of public health ethics in Germany, we discuss whether economic efficiency should be part of public health ethics and, if necessary, how efficiency should be conceptualized. Based on the welfare economics theory, we build a theoretical framework that demands an integration of economic rationality in public health ethics. Furthermore, we consider the possible implementation of welfare efficiency against the background of current practice in an economic evaluation of health care in Germany. The indifference of the welfare efficiency criterion with respect to distribution leads to the conclusion that efficiency must not be the only criteria of public health ethics. Therefore, an ethical approach of principles should be chosen for public health ethics. Possible conflicts between principles of such an approach are outlined.     

Ethics: the evidence of leadership

Today's leaders in health care are being challenged by many demands and issues. To confront these many demands, health care leaders must have the ability to make decisions based on ethics. To ensure the survivability of an organization, the leadership must have values grounded on ethical principles. The problem in today's health care organizations is that not enough emphasis is being placed on a culture of ethics within the organization and within the behavior of the leadership. This article addresses the ethical issues facing today's health care leaders. In this article, an overview of the history and philosophy of ethics is provided along with definitions, guidelines, and a model to assist the leadership in health care organization to pursue and to adhere to a more ethical course.     

Ethics of qualitative research: are there special issues for health services research?

BACKGROUND: An increasing volume of qualitative research and articles about qualitative methods has been published recently in medical journals. However, compared with the extensive debate in social sciences literature, there has been little consideration in medical journals of the ethical issues surrounding qualitative research. A possible explanation for this lack of discussion is that it is assumed commonly that qualitative research is unlikely to cause significant harm to participants. There are no agreed guidelines for judging the ethics of qualitative research proposals and there is some evidence that medical research ethics committees have difficulty making these judgements. OBJECTIVES: Our aim was to consider the ethical issues which arise when planning and carrying out qualitative research into health and health care, and to offer a framework within which health services researchers can consider these issues. RESULTS: Four potential risks to research participants are discussed: anxiety and distress; exploitation; misrepresentation; and identification of the participant in published papers, by themselves or others. Recommended strategies for reducing the risk of harm include ensuring scientific soundness, organizing follow-up care where appropriate, considering obtaining consent as a process, ensuring confidentiality and taking a reflexive stance towards analysis. CONCLUSIONS: While recognizing the reservations held about strict ethical guidelines for qualitative research, we argue for further debate of these issues so that the health services research community can move towards the adoption of agreed standards of good practice. In addition, we suggest that empirical research is desirable in order to quantify the actual risks to participants in qualitative studies.     

Klinik: Aufgaben und Kriterien für Klinische Ethikkomitees

This article provides a review on health care ethics committees and clinical ethics consultation in Germany. After a definition of these new institutions in the German health care system, detailed information on development, structures, implementation process and tasks of health care committees is provided. The three main tasks of health care ethics committees, clinical ethics consultation, development of ethical guidelines, and teaching and continuing medical education in clinical ethics are reported. Finally the author discusses the current professionalization and likely future developments of the field.     

Distributive Justice and the Introduction of Generic Medicines

Introduction: All countries face theissue of choice in healthcare. Allocation ofhealthcare resources is clearly associated withthe concept of distributive justice and to theexistence of a right to healthcare.Nevertheless, there is still the question ofwhether this right should include all types ofhealthcare services or if it should be limitedto selected types. It follows that choices mustbe made, priorities must be set and thatefficiency of healthcare services should bemaximum. Objectives and methods: Distributivejustice aims at ensuring that everyone hasaccess to necessary care based on thesubstantive ethical principles of equity andsolidarity. Resource allocation is paramount inpublic policy particularly with regardspharmacoeconomics. The objective of this studyis to determine the leading issues regardingthe marketing and trade of generic medicinesanalysing the reasons why there are hugedisparities between European countries withregards generic drugs acceptance bypractitioners. Results and conclusion: Distributivejustice aims at ensuring that everyone hasaccess to reasonable care based on the ethicalprinciples of equity and solidarity. However,universality implies always choice in accessand efficiency in delivery. It follows thatresource allocation is instrumental in publicpolicy particularly with regardspharmacoeconomics. The acceptance ofdistributive justice as a new ethical paradigmfor professional ethics implies that as long asthe best interest of the patient is not atstake physicians should regard the use ofgeneric drugs as a valid instrument to promotethe efficiency of the system and therefore as away to facilitate citizen's global access tohealthcare.