Ethical considerations in managed care
...l conduct and informed consent. The code is silent on such issues as futile care and marginal treatment (Higgins). Interestingly, moral dilemmas surrounding these two issues, as well as the concepts of moral justice, are the most highly publicized problems associated with managed care and lead to an erosion of the public’s trust in the healthcare industry. In general, the 34 statements of the ACHE code of ethics transcends the ethical guidance of the 7 statements listed n the AMA’s Principles of Medical Ethics, particularly in relation to managed care (Higgins, 2000). Ethical codes are also meant to provide general guidance and not be used as the answer to all ethical dilemmas (Higgins). However, the general nature of most statements and the complete lack of guidance on some primary issues illustrate the failure of the code to keep pace with current practices. Leaders in health care are left with little or no guidance from regulations and codes on managed care issues. Higgins (2000) believes that the ACHE, and other professional organizations should consider guidance statements specific to managed care issues to assist health care managers with ethical dilemmas. Although this undoubtedly would benefit managers, the study also, in my opinion, illustrates the need for healthcare managers to rely their own moral grounding and ethical philosophy when faced with managed care dilemmas. Povar et al. (2004) agrees that managed care has posed some previously unconsidered ethical challenges for all stakeholders. They review a statement of ethical principles for managed care compiled in 2001 by the Harvard Pilgrim Health Care Ethics Program that convened stakeholders: patients, physicians, managed care organizations, and medical ethicists. The argument of this group is that managed care alone, did not create the issues of resource rationing, quality care, medical necessity, or medical technology; and it should not be solely responsible for developing answers. Therefore, the group attempted to develop principle that governed the rights and responsibilities of all stakeholders (Povar et al.). The first principle centers on one of the primary premises of virtue theory: integrity (Badaracco, 1997, Johnson, 2005; Povar et al., 2004). The principle states that all stakeholders should be honest in their relationships. Clinicians have a moral, if not legal obligation, to be honest with patients about their health status, treatment alternatives, benefit limitations, costs, and benefits. Patients, in turn, should be honest about their health and their finances. They should expect providers to advocate on their behalf, but not to lie on their behalf to obtained services that would not otherwise be covered (Povar et al.). The second principle is that stakeholders share appropriate stewardship of health care resources (Povar et al., 2004). In other words, it is the obligation of all parties to respect the unique needs of individuals, but not to disregard the greater good: the resources for other patients and subscribers. Managed care companies and providers have an obligation to operate efficiently and preserve resources, but also not to withhold treatment arbitrarily or solely on cost (Povar et al.). This attempts to address the more difficult questions of justice as they pertain to futile or unnecessary care. The third principle is that all parties should foster an ethical environment for quality of health care (Povar et al., 2005). Studies have found that no real deterioration to health care quality appears to exist despite the controversy surrounding managed care (Higgins, 2000). Yet, it continues to be one of the most publicized concerns (Higgins). This principle is extended to contractual obligations that do not conflict with the other primary principles. It also recognizes the need for client confidentiality, another ethical issue of concern for managed care subscribers (Povar et al.). The final principle relates to meaningful disclosure, not only about clients care and options for care, but also about conflicts of interest and financial incentives to limit care. The term meaningful infers that disclosures should be simple, clear, and easy to understand (Povar et al., 2005). This combines professionalism with integrity in a more forthright way than other codes of ethics (Higgins, 2000). The statement of principles is relatively new and it remains to be seen if they are adopted as guidance by professional organizations. However, the statements, while still general in nature, appear to address many of Higgins’ (2000) specific concerns related to current codes of ethics. More importantly, while not regulations or treatises, the principles appear to be based on both virtue theory and Kant’s utilitarian theory, yet provide more specific guidance on today’s managed care dilemmas (Badaracco, 1997; Johnson, 2005). Seedhouse (2002) promotes the foundations theory of health to supplement the ethics code. He recognizes that ethics codes are, of necessity, general and subject to interpretation. In addition, each profession has its own code of ethics (physicians, managers, nurses, etc.) that may not be consistent. Seedhouse supports the theory that ethical considerations are grounded in character, and leaders must apply their own principles to moral dilemmas in accordance with virtue theory (Johnson, 2005; Seedhouse). Seedhouse recommends the use of the foundations theory specifically designed for healthcare as a guideline that crosses professions, cultures, and medical specialties, rather than across all stakeholders. Seedhouse (2002) argues that ethical codes, in an attempt to be universally appealing, must also be very broad in nature. He argues that universal ethical principles are, in fact, insufficient in that there is no absolute “common morality” across all cultures (Seedhouse). Seedhouse uses the example of the four principles approach (Beauchamp, 2003; Seedhouse). Although beneficence, non-maleficence, autonomy, and justice appear to be generally accepted principles, they are broad values and can be interpreted differently among people (Beauchamp, 2003; Higgins, 2000; Seedhouse). For example, a principle of justice would be to provide reasonable health care to all. However, the term reasonable is not well defined and has different meanings to the stakeholders (Seedhouse). A code that attempts to accommodate all values equally ignores the incompatibility of conflicting ethical philosophies, and thereby becomes ineffective (Seedhouse). Seedhouse (2002) believes that ethics cannot be delineated by codes and principles, separate from the individual’s moral basis. Health professionals derive ethical commitment from a desire to work toward a state of health. Therefore, he believes that a foundation that addresses what defines an individual’s optimal state of health will in turn guide ethical practice, making codes unnecessary. Because a state of health includes biological, educational, environmental, psychological and social needs, medicine may not always be the primary consideration in health care. As such, a foundation for health theory can be used across professions as a shared commitment to work for health (Seedhouse). Seedhouse’s (2002) foundations theory considers an individual’s basic needs (food, shelter, etc.), informational needs, education, social needs, and additional or crisis support. Work for health, in this theory, would assist in developing the basic building blocks necessary to enable an individual to develop. As the needs of an individual change over time depending on their circumstances, working for health may encompass different approaches, including those not consistent with traditional health care (Seedhouse). Seedhouse (2002) acknowledges that the article provides a limited view of foundations theory that may appear to be simplistic and unrealistic. His main points, however, are that it is possible to work together using a shared system of health, that the worker can commit to its shared values, and that given the theory Codes of Ethics are unnecessary. In fact, Seedhouse argues that Codes of Ethics may lead professionals away from sustained collaboration. By leaving unanswered ethical questions, codes are not effective in practice (Seedhouse). The foundations theory would serve as a basic guideline that combines practice and ethics, is based on the health care worker’s basic ethical commitment, and can be used across professions and organizations (Seedhouse). Like Khushf (1999), Goold (2001) also discusses the trust inherent in a physician-patient relationship and that, in today’s health care environment, trust needs to be extended to the institution. Like Seedhouse (2002), Goold also believes that organizational ethics goes beyond codes of ethics or contractual obligations. Goold believes that the issue of organizational ethics is largely unexplored in the research. Organizational ethics are generally perceived as a function of contractual obligations. However, contracts assume equal power, information, and consent for all parties, and neither patients, nor in some cases individual providers, have the same level of authority as the organizations. In light of this issue, she examines appropriate ethical frameworks for institutions (Goold). Grounding health care organizational ethics as a derivation of clinical ethics would drive institutions to simply support the moral aspects of health professionals’ work. Such a framework considers the traditional sanctity of the provider-patient relationship. But fails to address the administrative and socio-economic responsibilities of the organization (Goold, 2001; Khushf, 1999). Similarly, business ethics as they relate to commercial transactions fail to reconcile the mission of the organization with its administrative functions (Goold). Health care institutions are typically defined by both their contractual obligations and their social obligations (Goold, 2001). However, as issues of power, vulnerability, and equality exist in the institutional relationship, contractual obligations are inadequate to address ethical dilemmas. Health care institutions have a pseudo-fiduciary relationship with their patients that require different standards. Although enforcement of contracts and regulatory requirements provide some level of trust that institutions are meeting their obligations, they can also impact the institution’s ability to change and improve efficiency or quality. Therefore, Goold explores the use of self-imposed norms of behavior. There are limitations to external imposed standards such as cost and limited means of pro-actively protecting patients. However, a moral institution that adheres to basic standards of honesty, trust, caring, competence, and confidentiality is more likely to fully address all aspects of the organization and adhere to self-imposed norms (Goold, 2001). Health care institutions have obligations not only to the patients, but also to such groups as the community, employees, insurance purchasers, and potential patients and/or insurance enrollees. Goold suggest a morality based on relationships and defined by both the organization’s function and the roles each individual plays within the organization. Goold believes that institutional trust is based on beneficence and advocacy, tempered by institutional fairness. Issues of distributive and procedural justice are thus more important to institutional ethics than to individual ethics. Institutions are not only responsible for the care and interests of their patients, but to distribute benefits and costs fairly (Goold). This considers the institutions responsibility for all forms of management: clinical, administrative, social, and financial. It also recognizes the institution’s responsibility, not just to the individual patient, but to all stakeholders. Defining the ethical roles of the organization helps it to address conflicts on priorities and to engage in ethical priority setting (Goold, 2001). Organizational trust is dependent upon the actions f the individuals within it, and the individuals’ actions are guided by their trust in the organization. Therefore, Goold suggests that organizational ethics will inevitably go beyond basic moral standards of honesty and openness, and incorporate the combined perspectives of all stakeholders in the organization. The trust inherent in the institutional relationships will allow for the effective interaction of micro-ethical and macro-levels of ethical analysis (Goold). Illingworth (200) also addresses the inadequacy of business ethics as a framework for managed care, but from a different perspective. She argues that bluffing, puffing, and spinning are accepted practices in business and are inherently ethical. Such practices, however, are inappropriate for health care practices. Yet many providers, clients, and managed care organizations are already liberally using these practices to the detriment of health care (Illingworth). Bluffing refers to a deception in an arrangement where parties have agreed to have the usual guarantee of truth lifted. In negotiations, stipulating a high asking price with the expectation that the other party will counter with a lesser price that the seller is willing to accept. Puffing relates to the embellishment of a product’s quality. Spinning is a common public relations term and generally refers to placing a positive light on something that is potentially negative or damaging (Illingworth). These practices are considered to be morally ethical in business because they are expected and all parties have supposed knowledge of the deception. As Henry Taylor states “ falsehood ceases to be falsehood when it is understood on all sides that the truth is not expected (Illingworth, 2000, p. 65). In fact, businesses are considered to be disadvantaged if they are unable to use these tactics (Illingworth). Managed care organizations are guilty of bluffing when they fail to disclose benefit limitations clearly. Denials based on medical necessity or inappropriate levels of care are sometimes used to conceal exclusions due to high costs of care. Failure by organizations to clearly define their reasons or to use vague terms to establish criteria for payment allow for a form of positive spinning of benefit denials. Puffing techniques are used in advertising for managed care organizations in much the same way as it is used in commercial businesses (Illingworth, 2000). Providers can use these same techniques to resolve ethical dilemmas or conflicts of interest. Providers can exaggerate the serious nature of a patient’s condition to obtain services. In this way, they can ignore the contracting rules while still appearing to comply. They can meet the presumed needs of the patient without sacrificing reimbursement. They can also avoid lengthy appeals and contentious discussions with patients and managed care organizations. At times, such practices are done with the complicity of the client (Illingworth, 2000). Providers can also use deceptive practices to their own advantage with clients. Before managed care, providers were suspected of hiding information about the seriousness of an illness from a vulnerable patient. Refusal to disclose benefit limitations or conflicts of interest or not informing clients about alternative forms of treatment are deceptive practices that may promote the financial interests of the provider (Illingworth, 2000). According to Illingworth (2000), whether such practices by managed care organizations and providers constitutes a practical business procedure or an unethical deception depends on the warranty of truth. If providers have a quasi-fiduciary relationship with clients, then they have a duty of trust to their clients, and a warranty of truth is implied. In addition, because of the inherent vulnerability of patients requiring care, it cannot be assumed that “…it is understood on all sides that the truth is not expected” (Illingworth). The presumption of such deceptions can be damaging to the treatment relationship and ultimately can negatively impact the client’s care. As such, Illingworth (2000) makes the argument that health care cannot be solely treated as a business sand operate solely according to business principles. Health care is a necessity and patients have little control or choice concerning its delivery. Organizational ethics must then address the fiduciary responsibilities of health care and both the explicit and implicit values of the business of health care (Illingworth). Daniels (2001) addresses issues of managed care and ethics as they relate to counseling. It is reported that most counselors believe that managed care has a negative impact on their practice and that the negative perceptions stem primarily from ethical dilemmas. Daniels explores some of the most prevalent ethical issues fro counseling and the guidance available for ethical decision-making. These issues include informed consent, confidentiality, integrity, and conflicts of interest. The American Counseling Association (1995) code of ethics state that informed consent includes apprising clients of procedures, limitations, risks and benefits of service as well as other pertinent information. This includes limits on confidentiality, coverage, and treatment as required by the managed care organization. Compliance with ACA codes would require full disclosure prior to the start of treatment (Daniels, 2001). In fact. Counselors are required not to abandon clients that require additional treatment. Dan...