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.     

The United States; long-term and Federal policy.

Examines the need for uniform national policy for the provision of long-term care (LTC) services at an affordable price with access for all in need: points up the relationship between LTC issues and acute care policy; outlines seven basic principles for a comprehensive LTC system; lists problems to be solved and proposes alternative solutions for issues of chronicity, access, and cost control; and urges long-range comprehensive policy reform fo health care delivery and financing.     

Future issues in Children's Health Care: Addressing Psychosocial Concerns

A panel of experts, participating in a Delphi poll, identified significant issues facing psychosocial aspects of health care for children in the future In three rounds of feedback and evaluation, ten top future issues were composited in rank order chronic illness and complex health care needs, sociogenic problems, unequal access to health care, lack of financial resources for psychosocial services, increased focus on prevention, children without primary caregivers, complex ethical questions, family-centered care, training of health care professionals, and interdisciplinary integration Implications of these issues are discussed.     

Future issues in Children's Health Care: Addressing Psychosocial Concerns

A panel of experts, participating in a Delphi poll, identified significant issues facing psychosocial aspects of health care for children in the future In three rounds of feedback and evaluation, ten top future issues were composited in rank order chronic illness and complex health care needs, sociogenic problems, unequal access to health care, lack of financial resources for psychosocial services, increased focus on prevention, children without primary caregivers, complex ethical questions, family-centered care, training of health care professionals, and interdisciplinary integration Implications of these issues are discussed.     

Taking California health insurance into the 21st Century

California's system of financing and delivering health care is coming apart at the seams. High costs and large numbers of uninsured leave too many of the state's residents vulnerable to illness and exorbitant health care bills. A plan to reform the system must include: universal access, cost containment, equitable financing, a choice of systems, a unified plan, shared risk, and a greater emphasis on disease prevention.     

Economics and ethics in mental health care: traditions and trade-offs

BACKGROUND: Both economic and ethical perspectives are exerting increasing influence at all levels of mental health policy and practice; yet there is little consensus on how these two different perspectives are to be reconciled or explicitly incorporated into decision-making. AIM: This review article is directed towards a fuller understanding of the complex trade-offs and compromises that are or may be made by clinicians, managers and policy-makers alike in the context of mental health care planning and delivery. METHOD: We briefly outline a number of key principles of health care economics and ethics, and then focus on the particular incentives and trade-offs that are raised by these principles at three levels of the mental health system: government and society; purchasers and providers; and users and carers. RESULTS: At the level of government and society, we find (economically influenced) attempts to reform mental health care offset by concerns revolving around access to care: whether society is prepared to forgo economic benefits in exchange for improved equity depends to a considerable extent on the prevailing ethical paradigm. The implementation of these reforms at the level of purchasers and providers has helped to focus attention on evaluation and prioritization, but has also introduced "perverse incentives" such as cost-shifting and cream-skimming, which can impede access to or continuity of appropriate care for mentally ill people. Finally, we detect opportunities for moral hazard and other forms of strategic behaviour that are thrown up by the nature of the carer:user relationship in mental health care. CONCLUSION: We conclude by highlighting the need to move towards a more open, accountable and evidence-based mental health care system. Acknowledgement of and progress towards these three requirements will not deliver ideal levels of efficiency or equity, but will foster a greater understanding of the relevance of ethical considerations to mental health policies and strategies that are often influenced strongly or solely by economic arguments, whilst also demonstrating that equity must come at a price.     

Challenges for accessing and financing high-cost medicines in multipayer systems: case studies of multiple sclerosis in Malaysia

Timely and continued access to high-cost medicines for the management of chronic illnesses such as multiple sclerosis, are often constricted by its affordability for patients. Health systems also face challenges in arranging sustainable financing for populations with chronic illness in need of equitable and long-term access to high-cost medicines. In many low-to-middle income countries, pluralistic health payers within and beyond the public system contribute to health financing. The structures, processes and dynamics of access through these payers however, may have limitations and negative consequences for patients. In this paper, we present vignettes of case experiences from working individuals with multiple sclerosis in Malaysia, on their experiences and encounters when seeking access through public and private health payers. The Malaysian case and experience is an example of the public–private health care system challenges in providing sufficient access and financing to high-cost medicines. Themes include limited and interrupted hospital access, requirements to prove individual socio-economic deservingness for reimbursement, and confronting discrimination from employers as discretionary payers of medical care. These discussions reinforce the value of universal health access, pooled systems of financing and risk sharing to provide comprehensive health care access and reduce economic and health vulnerabilities in patients.     

The United States:

Examines the need for uniform national policy for the provision of long-term care (LTC) services at an affordable price with access for all in need; points up the relationship between LTC issues and acute care policy; outlines seven basic principles for a comprehensive LTC system; lists problems to be solved and proposes alternative solutions for issues of chronicity, access, and cost control; and urges long-range comprehensive policy reform for health care delivery and financing.     

英国“购买与提供分开”下的健康服务整合改革及启示

以人为本的整合型卫生服务体系是当前国际卫生体系发展的重要方向。鉴于英国卫生体系综合绩效在发达国家中的领先地位，在"购买与提供分开"的框架下政府同时负责筹资和服务组织的结构，这与我国卫生体系具有相似性，本文根据文献研究和现场调查，分析英国近年建设以人为本整合型卫生服务体系的内在逻辑和实践进展，并探讨其对我国的启示。研究发现，改革主要体现在三个层面：区域层面推动卫生部门内部各机构与跨部门服务的统一规划，并辅以转型基金、绩效考核和整合式的预算分配与决策机制；地方层面以公共卫生和医疗服务的筹资整合推动服务围绕人群健康进行协调，应对人群层面的健康问题；社区层面通过对全科医生执业模式进行再组织，在基层卫生网络基础上结合社区服务，综合应对个体和社区层面的健康决定因素。根据英国经验，本文提出：整合改革涉及多个层面，应当明确各自权责；统一的决策问责、协调的资源分配是推动整合的关键抓手；基层卫生发展需要在专业化基础上进行组织化。     

The impact of age on cost-effectiveness ratios and its control in decision making

Throughout Europe and in a number of other industrialized countries, the coming decades have been predicted to feature an increase in the proportion of patients who are elderly. This has led to considerable concern with respect to financing the health care system and has also increased the concerns about the efficiency of health care. Integrating ageing and efficiency issues, this paper examines the effects of age on the cost-effectiveness of medical interventions and its impact on decision making. First, at the clinical level, the relation between age and the cost-effectiveness of medical interventions is analysed. Second, at the population level, a framework is presented which allows researchers and decision makers to assess the impact of these effects on the decision-making process. It is shown that the allocation of health care resources at the macro-level is seriously impaired when age is ignored as a variable in cost-effectiveness analysis. Because clinical trials typically employ ‘young’ populations, when the data are extrapolated to the whole population the attractiveness of medical interventions in terms of cost-effectiveness may be considerably overestimated. Furthermore, the cost-effectiveness ratio may vary across countries or over time as a result of demographic or epidemiological variation. Economic evaluators should describe the impact of age, which should then be considered by decision makers to control for age effects.     

Translating psychosocial insight into ethical discussions supportive of families in end-of-life decision-making

A large number of Americans would rather rely on family and friends more than their physicians about end-of-life care and decisions. Moving beyond traditional clinical ethics and its dyadic focus on the physician-patient relationship, this article presents an approach to ethical decision-making at the end of life that is more inclusive of the patient's family and has the potential to advance social work practice in end-of-life care. Initial attention is given to how psychosocial and bioethical perspectives and practices interact to shape understanding of moral issues in end-of-life decisions. Morally relevant principles are then adapted from contextual therapy as being useful for including more of a family focus and viewing ethical decision-making at the end of life as a family process. Specifically, focus is on exploring the ethical dynamics of family systems that impact the decision-making process and translating psychosocial insight into ethical discussions that are supportive of families. The case of a patient with sudden and unexpected brain death and without advance directives demonstrates one family's unresolved grief and illustrates how its members were helped to reason morally about end-of-life choices. Contributions of a social worker and bioethicist are illustrated.     

Building evidence for legal decision making in real time: legal triage in public health emergencies

Similar to the triaging of patients by health care workers, legal and public health professionals must prioritize and respond to issues of law and ethics in declared public health emergencies. As revealed by the 2009-2010 H1N1 influenza outbreak and other events, there are considerable inconsistencies among professionals regarding how to best approach these issues during a public health emergency. Our project explores these inconsistencies by attempting to assess how practitioners make legal and ethical decisions in real-time emergencies to further critical public health objectives. Using a fictitious scenario and interactive visualization environment, we observed real-time decision-making processes among knowledgeable participants. Although participants' decisions and perspectives varied, the exercise demonstrated an increase in the perception of the relevance of legal preparedness in multiple aspects of the decision-making process and some key lessons learned for consideration in future repetitions of the exercise and actual, real-time emergency events.     

The role of public health in providing primary care for the medically underserved

Strategies designed to meet the health care needs of Americans should include the issues of access as well as financing. And primary care and clinical preventive services should receive as much national attention as acute care and long-term care. The public health system at the Federal, State, and local levels with its mandate to assure conditions in which people can be healthy must also be incorporated into the national debate. Publicly funded infrastructures for delivering primary health care have become a significant element of assuring access at the community level. This paper examines the expanding role of public health in assuring access to the delivery of primary health care and clinical preventive services to vulnerable populations within the larger issue of who should have access to care and how it should be made available. Special attention is paid to the part played by the Health Resources and Services Administration (HRSA) of the Public Health Service, which, in the Federal fiscal year that began on October 1, 1989, administered some $1.8 billion worth of programs for health care of targeted populations and for the support of training in the health professions.     

Toward a health care financing strategy for the nation. Report of the National Health Policy Seminar.

All people in the United States have a need for access to comprehensive high quality health care. Such need is so universal and fundamental, not only to personal health, but also to equitable pursuit of all opportunity in a modern and just society, that it is viewed increasingly in the context of rights. Although the current array of health financing programs--Medicare, Medicaid, employer-based medical care insurance benefits, private medical care insurance, and other current insurance methods--have major accomplishments to their credit in providing access to care, the United States falls short in guaranteeing that conceptual right. The result is that 35 to 40 million people in the United States have no insurance coverage at all for medical care expenses, and an unknown number of people have coverage that is grossly inadequate. In addition, our current medical care system is characterized by: significant barriers to equitable access to care, apart from lack of coverage of the direct costs; major deficiencies in services for rehabilitation, long-term care, and home care; extreme variablity in the utilization and quality of care. We also must acknowledge failures in fundamental programs that directly affect the health of our people, such as health manpower, housing, education, and protection against occupational and environmental hazards. However, these matters are outside the purview of this statement. We propose a program, under the leadership of the federal government, with state and local government and the private sector having significant roles to play, that will respond to these shortcomings in our health care system. The program would finance health services comprehensively and equitably, minimize duplication, inefficiency, and the uneven quality of care, and would emphasize health promotion and disease prevention.     

Role of a Clinical Ethics Committee in Residential Aged Long-Term Care Settings: A Systematic Review

ObjectivesTo conduct a systematic review of literature examining the establishment and operation of clinical ethical committees (CECs) in long-term care (LTC).DesignSystematic review.Setting and ParticipantsLTC recipients/family or staff.MethodsFive databases (Ovid Medline, Ovid Cochrane Library, Ovid PsycINFO, Ovid EMBASE, and CINAHL via EbscoHost) were systematically searched from their inception to May 8, 2020. The initial search was conducted on August 22, 2017, and updated on May 8, 2020, to identify peer-reviewed studies, commentaries, or editorials. The quality of studies was assessed using the Mixed Methods Appraisal Tool.ResultsThirty-three articles were identified for inclusion, of which 13 were primary studies. Most articles were set in the United States. The purpose of establishing a CEC in LTC was typically to assist in dealing with ethical issues and improve the quality of care. The articles described the roles of CECs to include prospective case consultation, case review, policy development, and ethics education. Articles rarely reported whether the CEC was required by or enshrined in law. Membership of CECs was between 4 and 20 members and most commonly included nursing staff, physicians, and directors/administrators. The rationale behind the membership was rarely described. For case consultation, articles described that CECs were typically convened upon referral. The resident issues which a CEC could address included end-of-life care decisions, autonomy/self-determination, and medical treatment decisions. The staff issues addressed by CECs included medical treatment decisions, end-of-life care decisions, and decision-making issues. The decision-making process followed by CECs varied. The outcome of a CEC meeting was typically a recommendation, whereas the implementation of CEC recommendations and decisions were rarely reported.Conclusions and ImplicationsThis systematic review identifies how CECs operate in the LTC setting. CECs have the potential to provide valuable support in addressing complex ethical issues in LTC; however, empirical research is required to determine their efficacy in the LTC setting.     

Economic development and the health care system in Hong Kong

This article describes parallel developments of the Hong Kong economy and its health care system. The purpose is to illustrate how the Hong Kong health system evolved in response to external and internal pressures generated by economic prosperity. The Hong Kong system illustrates the importance of clear policy making in the face of these pressures. In particular, issues of investment, financing and distribution of health services are examined in relation to hospital cost control and service accessibility. In the past, health care costs in Hong Kong have been controlled at the expense of limited accessibility of health services. At present, Hong Kong policy-makers are faced with the challenge of maintaining a sharp focus on cost control as they face pressure to expand and improve health care coverage for the citizens. So far they have responded by emphasizing management efficiency through reorganization. It remains to be seen whether this strategy can be successful without passing increased health care costs to the consumers.