Ethical Dilemmas in Healthcare.

Monday, July 03, 2006

Truthfulness or beneficent deception?

Recently I read an article in The New York Times, “Medical Misstep”. In this article, one of the healthcare professionals tells a story that happened in his hospital. A seriously ill patient was admitted to the hospital with multiple organ dysfunction. This patient was unable to make decisions for himself due to his critical condition. A blood transfusion was indicated, but the patient’s family refused because of religious reasons. One evening the on-call resident, unaware of the patient’s faith, ordered a transfusion. There were no clinical consequences. Disclosure would likely cause the family significant emotional distress. (Cohen 2006.) Healthcare professionals were facing the dilemma whether to disclose the truth to patient’s family or not. Readers were asked this very question. Their answer was to tell the truth. I agree with the readers that the truth must be told.

This article made me think beyond this particular situation. Healthcare professionals face the dilemma whether to tell the truth or beneficent deception when the medical error occurred or when the patient was diagnosed with a serious and perhaps incurable illness.
In my opinion, communications between healthcare providers and patients should be truthful. Patients must know that they can trust and believe their doctors. Healthcare professionals more than anyone else have an obligation to tell the truth and it cannot be overridden by speculation about possible harms. The physician’s duty to tell the truth is not limited to good news. By not disclosing the error the healthcare institution would jeopardize its reputation, lower the morale of the employees and perhaps face litigation. By not telling the truth about the seriousness of patient’s diagnosis, healthcare professionals would omit the patient’s right to know the truth. The patient has a need for the truth if he or she is to make rational decisions about actions and plans for life. (Jonsen 1998.)

In my opinion, when healthcare professionals make the decision not to advise the patient or family members of a medical error or a serious diagnosis, they are trying to avoid possible negative ramifications for themselves, not the patient or the family. It should not matter how difficult it may be for the patients and their families, as they have a right to know the truth. There is no medical error or illness that would not cause some emotional distress. Consequently, physicians must be very careful when they speak to their patients or the family members about the medical error or a serious diagnosis. “Speaking truthfully and relating the facts of the situation does not preclude a manner of relating the facts that is measured to perceptions of the hearer’s emotional resilience and intellectual comprehension. The truth may be “brutal”, but telling of it should not be.” (Jonsen 1998.)

Honesty is an essential part of the healthcare industry. Patients should be able to count on their healthcare providers and trust them. Trust is a key element of the foundation of the physician-patient relationship, without which the relationship is sure to deteriorate.

1.) Randy Cohen. (2006). The New York Times. The Ethicist: Medical Misstep.
2.) Jonsen A., Siegler M., Winslade W. (1998) Clinical Ethics: A Practical Approach to Ethical Decisions in Clinical Medicine, Fourth Edition. USA: McGraw Hill Companies, Inc.

Sunday, June 25, 2006

Medical Tourism.

People who are not covered by either private or government-sponsored health insurance programs are referred to as uninsured. About 44 million Americans, most of them employed, do not have a health insurance. The voluntary system of health insurance in America is the primary cause of leaving a large part of the population uninsured. Many Americans are too poor to have an insurance plan and too rich to qualify for the Medicaid. Some predict that by 2015 more than 1 in 4 workers will be uninsured.
Healthcare in the United States leads the world in the latest and the best in medical technology, medical training and research. Unfortunately many Americans cannot benefit from that. Person who does not have insurance would have to pay for the medical services he or she needs out of his or her pocket. Interestingly, the prices are different. The insurance companies are usually paying less than an individual would be charged for the same medical procedure. Even insured people cannot receive all the services they need due to limited coverage their health plan provides.
Apparently, some people have found a way to deal with the situation. Medical tourism is now an option. People are being offered an option to travel to another country to receive the medical services they need. The reason is simple - the prices are much more reasonable abroad. The high-quality of care and cut-rate surgeries are available in the countries like India, Thailand, Singapore and Malaysia. For example, it would cost $90,000 to have a herniated disk repaired in the United States and less than $10,000 in Bangkok. The agencies that provide these types of services are reassuring us that the quality of care in foreign hospitals is very competitive. Many of the doctors graduated from American medical schools. To cater to an international clientele, many private hospitals abroad are applying for accreditation from the Joint Commission International, which is a part of the institution that accredits most U.S. hospitals.
A growing stream of Americans is choosing to travel to another continent to undergo certain medical procedures. The array of the procedures is very broad, from a face-lift and tummy tuck to herniated disk replacement and sophisticated heart surgeries. In addition to medical treatments, people get to be actual tourists, thus being able to see other countries and learn about the different cultures.
The growing trend of medical tourism may present serious competition for American hospitals in the near future.

1.) Med Retreat: Where smart medicine and exotic travel come together.

2.) Joint Commission Resources.

Monday, June 19, 2006

“The Magic of the Family Meal.”

Doesn’t it feel like the right thing to have dinner together with your family every night? In most families with their busy schedules, dinner is the only time when all the family members can actually see each other, talk about their achievements and their problems, or otherwise spend quality time together.
I always knew that there was something more with this tradition than just quality time. However, even this simple reason should be enough for all families to try to get together at one table and share a meal as often as they can.
Well, here it is!
“The statistics are clear: kids who dine with their parents are healthier, happier and better students, which is why a dying tradition is coming back”, says Nancy Gibbs in her article in Time magazine.
Studies show that the more often families eat together, the less likely kids smoke, drink, do drugs, get depressed, develop eating disorders and consider suicide, and the more likely they are to do well at school, delay having sex, eat their vegetables, learn big words and know which fork to use.
Beyond promoting balance and variety in kids’ diets, meals together unite families and build its identity and culture. In addition, kids get to learn from their parents how a problem is solved, learn to listen to other people’s concerns and respect their tastes. Parents are undervaluing themselves, when sending their kids to every conceivable extracurricular activity and not allowing their children to spend more time with them. Just talking to Mom and Dad is crucially important in the development of a healthy and happy child.
So start having family dinners! At the beginning it may feel that you have nothing to talk about, or you don’t have time for that, but allow it some time!
Researchers from the Columbia University found essentially that family dinners get better with practice. The more families eat together, the better the experience is likely to be, the healthier the food and the more eager family members are to engage in meaningful conversation.

The Magic of the Family Meal, by Nancy Gibbs. Time. June 12, 2006, pg.53, 4pgs.

Thursday, June 08, 2006

Patient confidentiality.

One of the most pressing ethical issues healthcare providers face is acting in the best interests of the patient when reporting requirements may be in conflict with patient confidentiality.
Confidentiality is one of the mechanisms by which a person’s right to privacy is recognized and honored. The obligation to preserve patient confidentiality is important for several reasons.
First, preserving confidentiality is necessary to protect individual privacy and ensure individuals retain control over their public image.
Second, preserving confidentiality demonstrates trustworthiness and maintains integrity in the physician-patient relationship.
Third, preserving confidentiality enables patients to avoid harm, such as discrimination.
In addition, preserving patient confidentiality encourages patients to be candid with their healthcare providers. For people who would avoid medical care without a guarantee of confidentiality, it is prerequisite for access.
Preserving confidentiality is essential to healthcare. Fulfilling this obligation is, however, complex. There are pressures to disclose health information to third parties for a range of reasons:
- Sharing information with other healthcare professionals treating patient often necessitates widespread disclosure.
- Obligatory disclosure might arise in occupational health or might be required by a court. - The most powerful arguments in favor of breaching confidentiality turn on the need to prevent harm to others. Disclosures which may prevent child abuse or homicide are some of the examples.
-There are areas where statutory law requires healthcare professionals to breach the duty. An example of this is the requirement to notify certain infectious diseases to public health authorities.
Preserving confidentiality is a central part of the doctor-patient relationship. As with any relationship, there is scope of misunderstandings and betrayals. The best way to ensure that patients are aware of how their information might be accessed and protected is to discuss the confidentiality issue with patients. Open discussions may prevent inadvertent disclosures and minimize harm to patients; they also provide an opportunity to clarify reasons for sharing information when this is an integral part of better care.

Clinical Confidentiality in primary care. Spicer J. Practice Nurse. Nov. 11, 2005, Vol.30, Iss.8, pg.31, 3 pgs.
Introduction to Clinical Ethics, edited by Fletcher J., Lombardo P., Marshall M., Miller F. University of Publishing Group, Inc. 1997, Frederick.

Monday, June 05, 2006

“Time” magazine (May 1, 2006) has a great article.
Q. What Scares Doctors? A: Being a Patient.
What insiders know about our health-care system that the rest of us need to learn, by Nancy Gibbs and Amanda Bower.,10987,1186553,00.html
Apparently, even being a doctor does not help you in case of a serious illness. This article describes the feelings of doctors, when they have to deal with the healthcare system as patients. There are many examples in this article that illustrate the many different kinds of problems that patients of the medical institutions can possible face. However, certain things could be done in order to improve your chances to get proper treatment in a medical institution. The authors of this article interviewed doctors, who were victims of improper treatment and had to deal with medical errors. It is logical to assume that doctors gain much better perspective of the overall healthcare system when their role is reversed and themselves are in the relatively helpless role of the patient.
In this article, since the main actors are doctors and patients at the same time, they can provide valuable advice for non-doctor patients. Here are some of the subjects that were discussed:
-How to find the right hospital.
-How to find the right doctor.
-How to get the right care.
-How to survive July. (“The new interns and residents begin in July1. There is a very morbid joke: don’t get sick on July 4, weekend”)
-How to survive technology.
I believe you will find the subject article rather interesting and most informative.

Tuesday, May 30, 2006

Medical errors.

Medical errors should not be confused with risks and side effects, whose incidence is known but whose occurrence is not avoidable.
There two major ethical imperatives: 1.) avoid errors whenever possible and, when they do occur, 2.) do right by the people who are harmed.
Doing the right thing when an error occurs requires a broad view because patients are not the only ones who may be harmed. Physicians and other medical professionals may be emotionally devastated. Organizations need to help all staff cope effectively with those issues.
When an unavoidable error has led to significant harm, doing right by patients and families should be a primary focus. Patients and families need to be told what happened, kept abreast of the investigation and informed about the efforts to prevent reoccurrences. Healthcare organizations should also offer reasonable compensation that will place those who are injured as close as possible to the position they would have been in had the error not occurred.
This is not only the right thing to do, but doing so can yield further benefits. If patients and families know about the error, they can provide additional information to help prevent similar errors. Disclosing the errors to the families and involving them in a discussion about their care helps avoid lawsuits.
Those who suffered from the error, in turn, may find personal value and meaning while participating in the organization’s improvement process.

Managing Ethically: An Executive’s Guide, edited by Paul Hoffman and William Nelson. Chicago: Health Administration Press, 2001.

Friday, May 26, 2006

Ethical problem solving.

Any healthcare administrator is dealing with ethical dilemmas on a daily basis.
I believe, it can be challenging to solve the problem ethically. However, since healthcare executives set an example for their employees, it is very important for them to pay close attention while addressing ethical dilemmas.
In my opinion, medical errors are one of the most challenging issues to solve. Looking at the situation described in my previous posting and also at the Paradise Hills Medical Center story, where governing board and physicians decided not to disclose the information that the number of patients received wrong amounts of radiation during their treatments, it is clear that these type of issues are not easy to address.
Most hospital boards and chief executive officers currently cite patient safety as one of their top priority issues. By not addressing the medical error issues form an ethical standpoint, the healthcare provider jeopardizes its main duties to the patients, employees and society. There is a wrong assumption that by addressing this type of the problem managers would hurt the reputation of the physicians and nurses, and the reputation of the healthcare institution as a whole. Covering medical errors may seem like a possible option in the short run, but in the long run it will have an adverse consequence. Not disclosing the errors hurts patients, morale and reputation of the healthcare organization. In turn, addressing the medical error issue helps to change the system and decrease likelihood of the same adverse event occurring again.
Addressing medical errors does not necessarily result in someone being punished. Punitive action is only appropriate if an individual has knowingly and intentionally taken action to cause harm. One of the biggest mistakes that healthcare managers make while solving this kind of ethical problem is that they are trying to find a person to blame. Usually, it is the individual at the end of the process that went wrong in many places and often many times previously. When an error leads to an adverse event or harm, emotions contribute to the situation: anger from patients and families, fear of lawsuits from practitioners and guilt from those involved. The common response is usually to identify a person at fault and take punitive action against the person. This type of a problem solving is neither ethical nor practical.
Every day, patients are harmed by healthcare processes and systems. Within healthcare organizations, it is management’s responsibility to demonstrate and prove their commitment to patient’s safety and set an example of ethical behavior. By properly addressing ethical issues, healthcare managers will greatly contribute to improving patient safety, employee satisfaction and the reputation of the healthcare institution.

The Tracks We Leave: Ethics in Healthcare Management, by Frankie Perry. Chicago: Health Administration Press, 2002.
The Healthcare Quality Book: Vision, Strategy, and Tools, by Scott B. Ransom, Maulik S. Joshi, and David B. Nash. Chicago: Health Administration Press, 2005.