Bioethics programs called to address “new normal” under health care reform

But some are facing fiscal threats

In the eyes of cost-cutting hospital administrators, bioethics programs are sometimes perceived as a luxury rather than a necessity. “During periods of austerity, bioethics programs are often the first to not receive funding or not be maintained,” says Joseph J. Fins, MD, MACP, the E. William Davis, Jr. Professor of Medical Ethics and chief of the Division of Medical Ethics at Weill Cornell Medical College, and director of medical ethics and attending physician at New York Presbyterian Hospital-Weill Cornell Medical Center in New York City. “A number of programs have recently come under threat.”

“I do fear that some programs may be facing budget cuts. These are difficult times for institutions to take care of all of their needs. On the other hand, I also believe that there are some programs that seem to be expanding and doing well,” says Ruth L. Fischbach, PhD, MPE, director of the Center for Bioethics at Columbia University in New York, NY.

Bioethics programs often lack departmental standing or the historical funding lines of mainstream departments, putting them at a disadvantage compared with more traditional lines of study, notes Fins. “It may be a secondary position for faculty members — their home program is O.K., but the secondary program is put at risk,” he says.

If bioethics faculty have tenure in a home department, that department would need to be eliminated in order to cut their position, but this isn’t necessarily true of the tenured faculty member’s secondary department, he explains. “Faculty may have tenure in the Department of Medicine, and they might keep the faculty but take them out of the bioethics program. There are very few tenured spots in bioethics because the discipline is still relatively young,” says Fins.

Various divisions and centers in bioethics programs have different political standings within the institution, making them vulnerable in a way that established departments aren’t, says Fins. “If our core mission is our patients, and the integrity of the workforce is central to the service we provide to our patients or the science we produce, I think bioethics is our core mission,” he says. “You only appreciate the centrality of the work after there is a problem.”

Another challenge involves the interdisciplinary status of bioethics programs, which might bring their scholarly legitimacy into question. “In fact, interdisciplinary programs are just as relevant and often more relevant then a single discipline operating in a silo,” argues Fins. “The most challenging problems involve at least two disciplines, and often more.”

Fins says that bioethics is perhaps the most successful example of a discipline that brings scholars together from different parts of the academic spectrum to work collaboratively on truly complicated questions. “It’s important to cultivate relationships,” stresses Fins. “We are still struggling with the scholarly legitimacy of what we do, and we may not have as many allies as we would like.”

Current need is great

“Bioethics programs should be supported, as they provide essential information and encourage thoughtful consideration of burgeoning advances in biomedical technology,” says Fischbach. “We must always keep in mind the bioethics mantra — it’s not what can be done; rather, it’s what should be done.”

While bioethics programs are at risk when budget cuts are being considered, the programs are especially important at this time to ensure that ethical choices are made, emphasizes Fins, and will be needed to preserve the integrity of health care systems as they begin to implement the Patient Protection and Affordable Care Act. “This will alter the way services are provided.

We are going to have a different structure where the old norms could conceivably change,” he says. “It’s important to have somebody out there stressing that there are certain ethical principles that need to be adhered to in whatever system that is created.”

Fins points to a 2011 report from the Presidential Bioethics Commission that recommends that bioethics explain the “why” of regulations to investigators.1 “A lot of us are beginning to see that a regulatory approach is insufficient. The regulatory scheme of the [Institutional Review Board] isn’t equipped to explain the ethics underlying their work,” he says.

If cuts made to bioethics programs render them less effective, fundamental questions of patients’ rights and training the next generation of providers is at risk, warns Fins. “In times of change, people need to know what those principles are and how to adapt them to the new normal, because there is going to be a new normal,” he says. Here are changes that Fins says need to occur:

• Most people doing clinical ethics consults aren’t being compensated for those activities currently, which calls for bioethicists to work with organizations such as The Joint Commission to develop standards for these consults.

“We need to further professionalize that activity. Hospitals need to be accountable for the quality of the consultation work that they do and have a revenue stream attached to that functionality,” he says. “We need to minimize the variance so patients are better served. Nowhere else in the health care system do we tolerate that variance.”

• Medical informatics, electronic decision aids, and care provided via email will need to blend with continued responsibility of the individual.

“These are ethical questions that require individuals well versed in informatics and ethics to sort out,” says Fins.

• Bioethicists will need to work closely with clinicians and scientists to address new ethical questions posed by the reconfiguration of the health care system, such as medical homes, new organizational structures, providers working more closely with other disciplines, and doctors sharing clinical space with nurses and other colleagues.

“We will need to figure out who is responsible for what, when it’s a team effort more than an individual effort,” says Fins. “If you don’t adequately fund the medical ethics infrastructure, there are not going to be people to answer these questions with the degree of sophistication required.”

• The bioethics community has to secure a reliable funding stream, either through the National Institutes of Health, an extramural grant program that has yet to be fully articulated, or through some type of indirect cost recovery through research grants on the research side, and on the clinical side, by developing expertise in the area the bioethicist works in.

“In academic medical centers, the era of the generalist ethicist has passed. People who are going to work in cardiology, neurology, or psychiatry will need to know issues specific to that space,” says Fins. “That will be very important for you to remain relevant with your investigator colleagues.”

Reference

  1. Presidential Commission for the Study of Bioethical Issues (2011). Moral Science: Protecting participants in human subjects research.

Sources

  • Joseph J. Fins, MD, MACP, Chief, Division of Medical Ethics, Weill Cornell Medical College, New York City. Phone: (212) 746-4246. E-mail: jjfins@med.cornell.edu.
  • Ruth L. Fischbach, PhD, MPE, Professor of Bioethics, Director of the Center for Bioethics, Columbia University, New York, NY. Phone: (212) 305-8387. E-mail: rf416@columbia.edu.