Ethical Challenges of Healthcare Reform

1
Ethical Challenges of Healthcare Reform

• Laurence B. McCullough, Ph.D.
• Dalton Tomlin Chair in Medical Ethics and Health
  Policy
• Center for Medical Ethics and Health Policy
• Baylor College of Medicine
• Houston, Texas

2
Healthcare System or Gemish?

• A system is a clear, consistent, coherent,
  centrally led and managed service or production
  process
• We do not have a healthcare system in the United
  States
• We have a healthcare gemish
• Private and public providers and payers secular
  and sectarian providers federal and state
  regulation
• There are systems within the gemish VHA, Medical
  Corps of armed services, Indian Health Service,
  Hospital Districts in Texas
• No one individual is in charge no CEO of US
  healthcare
• Healthcare professionals and organizational
  leaders have always been in charge of patient
  care and will still be under heathcare reform

3
Professional Integrity

• Lead change the way it always occurs in our
  democracy, from below
• On the basis of professional integrity, a
  professional virtue that governs in all
  healthcare settings, systems and gemishes alike
• Professional integrity
• Practice medicine, conduct research, and teach to
  standards of intellectual and moral excellence
• Intellectual excellence Submit all clinical
  judgment, decision making, behavior, and
  organizational policies and practices to the
  discipline of evidence-based reasoning
• Moral excellence Commit to the protection and
  promotion of the patients health-related
  interests as ones primary concern and
  motivation, keeping individual and guild
  self-interest systematically secondary
• Gregory J 1772 Percival T 1803
• Healthcare professionals have an obligation,
  based on professional integrity, to provide
  quality healthcare

4
Integrity-Based Improvement of Patient Care

• Poor quality healthcare Unmanaged and therefore
  uncontrolled variation in the processes of
  patient care, resulting in (a) unmanaged and
  therefore preventable mortality, morbidity, lost
  functional status, and unnecessary pain,
  distress, and suffering and (b) unmanaged costs
• Provision of poor quality healthcare is
  inconsistent with professional integrity
• Intellectual excellence is violated by
  non-deliberative clinical judgment and practice
  that results in unmanaged variation
• Moral excellence is violated by (a) preventable
  mortality, morbidity, lost functional status, and
  unnecessary pain, distress, and suffering and (b)
  professionally irresponsible use of resources
• Provision of poor quality healthcare is
  economically wasteful, which is socially
  irresponsible

5
Integrity-Based Improvement of Patient Care

• Quality healthcare Responsibly manage variation
  in the processes of patient care, aiming to
  improve outcomes
• Identify components of the process of patient
  care
• Identify components that do not affect outcome
  and eliminate them
• Incrementally improve components that do affect
  outcome, alert to risk of making things worse,
  especially in complex processes of patient care
• Patients preferences will be (steeply)
  discounted
• Quality healthcare is primarily a
  beneficence-based, not autonomy-based concept

6
Integrity-Based Improvement of Patient Care

• Result of integrity-based improvement of patient
  care The healthiest possible patient
• Primary, secondary, and tertiary prevention
• The healthiest possible patient is the least
  expensive patient
• Integrity-based improvement of patient care is
  the means to responsibly manage the cost of
  healthcare
• Keep the horse (quality) in front of the cart
  (cost)

7
Integrity-Based Improvement of Patient Care

• Improved quality of patient care will prevent
  unacceptable opportunity costs
• An unacceptable opportunity cost occurs when
  clinicians use a clinically non-beneficial
  resource for a patient and that use blocks access
  to the resource for another patient who could
  clinically benefit from the use of that resource
• A major problem in responsible use of critical
  care beds, e.g., patient with multi-organ system
  failure on full code status

8
Integrity-Based Improvement of Patient Care

• Improved quality of care will also prevent
  rationing
• Rationing Denial of access to process of patient
  care that is reliably expected, i.e., supported
  in evidence-based reasoning, to be clinically
  beneficial
• Rationing is not permissible in integrity-based
  clinical practice and organizational policy
• Denying access to clinical management that does
  not meet modicum of benefit test is not
  rationing
• Doing less than has been done in the past is not
  rationing
• Incentivizing use of less expensive but
  equivalently effective clinical management is not
  rationing
• Healthcare professionals and organizational
  leaders should openly refuse to cooperate with
  organizational or health policies that result in
  rationing, because rationing is destructive of
  professional integrity and therefore destructive
  of organizational culture of professional
  integrity

9
Response to Era of Accountable Care Organizations

• Accountable care organizations (ACOs)
• ACOs are best understood as affiliations of
  health care providers that are held jointly
  accountable for achieving improvements in the
  quality of care and reductions in spending.
• Greaney TL 2011

10
Response to Era of Accountable Care Organizations

• Creating ACOs will not eliminate the healthcare
  gemish
• Physicians, other healthcare professionals, and
  healthcare organizations already have ethical
  obligation, originating in the eighteenth
  century, that should guide the development and
  leadership of ACOs To become and remain
  accountable for the quality of patient care
• John Gregory (1724-1773) called for
  accountability of physicians to scientifically
  sophisticated laypersons for the quality of
  patient care
• Gregory J 1772
• Thomas Percival (1740-1804) called for
  accountability of physicians and surgeons to each
  other for the quality of patient care
• Percival T 1803
• Percival also called for leadership of healthcare
  organizations to be accountable to the ethics of
  clinical practice, with professional
  responsibility disciplining economic concerns of
  healthcare organizations
• ACOs should be based on these long-established,
  ethically justified forms of accountability

11
References

• Greaney TL. Accountable care organizations the
  fork in the road. New Engl J Med 2011 Jan
  6364(1)e1. Epub 2010 Dec 22.
• Gregory J. Lectures on the Duties and
  Qualifications of a Physician. London W.
  Strahan and T. Cadell, 1772. In McCullough LB,
  ed. John Gregorys Writings on Medical Ethics and
  Philosophy of Medicine. Dordrecht, Netherlands
  Kluwer Academic Publishers, 1998 161-248.
• Percival T. Medical Ethics, or a Code of
  Institutes and Precepts, Adapted to the
  Professional Conduct of Physicians and Surgeons.
  London Johnson Bickerstaff, 1803.

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Ethical Challenges of Healthcare Reform

• Laurence B. McCullough, Ph.D.
• Dalton Tomlin Chair in Medical Ethics and Health
  Policy
• Center for Medical Ethics and Health Policy
• Baylor College of Medicine
• Houston, Texas