Ethical "pushback" may be needed with cost-containment efforts
Narrow focus on profitability is concern
Some worry that economics rather than ethics is driving change in the health care system; and that profitability, rather than justice and patient benefit, is becoming the focus of cost-containment, says Bruce Jennings, MA, director of bioethics at the Center for Humans and Nature in Dobbs Ferry, NY.
The 2013 Hastings Center Guidelines for Decisions on Life-Sustaining Treatment and Care Near the End of Life (Oxford, 2013) acknowledge cost as an ethical concern in health care.
Discussing treatment costs and advocating for patients who lack the means to pay for potentially beneficial treatment supports informed decision-making because unforeseen out-of-pocket costs can create burdens for patients or families, says Nancy Berlinger, a research scholar at The Hastings Center and first author of the Guidelines.
Berlinger recommends supporting a constructive, ongoing process of internal discussion about how organizational resources are allocated, including charity-care funds, and about the pressures that cost considerations place on professionals and teams.
"This can lessen tensions, and support the development of institutional policy that is fair to different patient populations and that compensates for known problems," says Berlinger.
Controlling costs is essential
The Guidelines offer detailed discussion strategies for institutions on this challenging issue, in addition to recommendations for professionals on how to talk with patients and families about cost.
"Although we avoid the word, we do have implicit rationing in our health care system, and controlling rising health care costs is essential," says Jennings, one of the authors of the Guidelines and a senior advisor to The Hastings Center and a Hastings Center Fellow. The central ethical concern is that a narrow point of view about cost containment and profitability will drive both access to care and individual treatment decisions unfairly.
"The fact that health care systems are increasingly profit-oriented is a bigger social policy issue than the Guidelines could tackle; and frankly, bigger than the field of bioethics," he says.
Clinical ethicists and other ethics leaders in health care institutions can help institutions move toward the goal of cost-effective care that is also better care in these ways, says Berlinger:
- Becoming well-informed themselves;
- Including health care cost as a regular topic in ethics education for clinicians and administrators;
- Looking for opportunities to collaborate with colleagues in areas such as care utilization, which explicitly aim to control costs;
- Promoting institutional discussion of resource allocation and the cost of care. For instance, they can convene and facilitate discussions, using the strategies described in the Guidelines.
"Better care is not necessarily the least expensive care," notes Berlinger. "Providing patients with access to needed care may require upfront investments."
Patient care adversely affected
The authors of the Guidelines heard concerns from many health care professionals about their perception that financial goals are adversely affecting patient care, through management pressures being placed on health care facilities and physicians.
"It would have been silly to try to come up with guidelines to address this in a straightforward sense — to say, for instance, that 'It's ethical to spend an unlimited amount of money on this patient, but not for this patient,'" says Jennings.
Instead, the authors tried to imagine systemic ways in which a group medical practice, hospital, or health care system could address this concern. One important issue identified in the Guidelines is the need to educate physicians and other providers.
"First, they need a better understanding of what the cost factors are," says Jennings. Many physicians don't know the cost of the treatment options that they are discussing with their patients.
"Ethical, humane patient care can also be good business. There need be no real conflict between the two," underscores Jennings.
Many studies indicate that cost-effective systems can also have good outcomes. "It's really hard to make a case that we are being unethical to patients and families if we practice more comparative effectiveness and research-based care," says Jennings. "But the devil is in the details, and any system can be gamed by greed."
There is a need to guard against slipping into a narrowly cost-conscious mentality, he says, but there is also a need to embrace cost-containment as a good thing for society.
"The financial payers might say, 'Let's just pay less and let the chips fall where they may,'" says Jennings. "The ethics pushback has to be, 'Let's spend less to drive profits, worry less about shifting costs to patients, and concentrate more on spending effectively for better care.'"