Order 1257985: Ethical Issues With an Aging Population

2010, Vol. 14, No. 4 27

Key Words: Aging patients, distributive jus-

tice, resource allocation, healthcare ra-

tioning, organizational decision making

model

Introduction

Healthcare costs have dramatically risen

over the last 15 years. This has created a so-

cietal concern as to whether or not the

world’s healthcare resources are being dis-

tributed in the most fair and useful fashion.

Increasing governmental demands to follow

cost control policies, eliminate waste, and

increase efficiency have placed patient in-

terests secondary to healthcare delivery

(Howe & Lettieri, 1999). The fundamental

question raised in healthcare resource allo-

cation, i.e., rationing, is, “Who decides

what care is not worth the cost?” The deci-

sion maker can be the patient, the physician,

the healthcare facility, or other third parties.

However, patients can be assisted into mak-

ing that decision by a provider, organiza-

tion, or insurance company whose main

objective is cost control. The aging are

often the most vulnerable to allocation of

resources due to their increased likelihood

of illness and chronic disease.

Establishing rational protocol for the al-

location of healthcare resources is critical

for a present-day society to achieve, espe-

cially with the rise in the aging patient pop-

ulation. In order for a protocol to be fair,

classic and contemporary theories agree es-

tablished policies must be transparent to the

public, defined with clarity, explain the

value of money in distributing healthcare

resources, have an established framework

for principled decision making, and have a

regulatory process for limit setting and dis-

tribution (Darr, 1997; Dracopoulou, 1999;

Mill, 1871, Rawls, 1999; Rothbard, 1998;

Runciman, Merry, & Walton, 2007). If con-

sensus can be reached by all parties in-

volved, including providers, patients, and

caregivers on the basis of distributive jus-

tice, then a mechanism can be established to

determine how to set fair limits on health-

care. Such mechanisms allow medical pro-

fessionals to be empowered to review all

social and ethical decisions against the prin-

ciples in order to determine whether these

allocation decisions both conform to ethical

standards and deliver the best care.

rationing by Social Criteria

In the United States, treatments for

chronic renal failure are double the rate of

Great Brittan, although the rates of dialysis

for young people are comparable among the

two countries. Kidney transplants are per-

formed at the same rate in both the United

States and in Great Britain since a success-

ful transplant in a younger patient will be

less costly than dialysis and is also a solu-

tion to kidney disease. Those patients in the

United States who receive federally funded

dialysis for kidney failure would not receive

treatment in Great Britain due to age. The

thought is that since they are older and have

a higher susceptibility for death then it is

not of social benefit to use the publically

funded dollar to treat them (Blumenthal,

Moon, & Warsharsky, 2003).

Research has given evidence to the fact

that medical costs are driven by technologi-

cal advancements. New medical technolo-

gies are introduced and funded by various

sources, including hospitals, governments,

private sector groups, and stakeholders.

These technologies claim to save lives, but

given the rising cost of healthcare it may

only be young lives that are saved by such

technology. The social criteria set by the

U.S. government, medical organizations,

and providers determine who will receive

what portion of healthcare in order to maxi-

mize the dollar.

Distributive Justice

The theory of distributive justice requires

healthcare access and resources are fair and

equal to everyone who shares the same

health need. Humans all have the same

basic healthcare needs, which include the

treatment of illness and the prevention of

illness (Russell, 2002). According to John

Rawls (1999), a major theorist on distribu-

abstract

Healthcare allocation among aging patients is at the forefront of ethical discussions.

the ultimate ethical issue of aged-based rationing is not whether too little or too much

treatment is offered, but rather establishing a protocol for seeking optimum reasonable

treatment based upon the medical condition of aging patients. Without an established

model, aging patients go without needed healthcare resources. the ethical issue that the

model will address is not one of prolonging or terminating life, but giving resources to

those who fairly deserve them. this paper describes an organizational decision making

model for healthcare resource allocation among the aging patient population based

upon the theory of distributive justice.

Caring Enough to Provide Healthcare: An Organizational Framework for the Ethical Delivery of Healthcare Among Aging Patients Heather D. Craig, MPH Walden University

28 International Journal for Human Caring

tive justice, it is unjust to risk inadequate

access to healthcare since healthcare is a

centrally important primary social good

comparable to freedom and the social basis

of self-respect. Rawls (1999) stressed the

importance that each member of society, no

matter of position or background, has an

equal right to the most extensive health re-

sources society offers.

Rawls’ (1999) theory included healthcare

institutions in the background of situations

involved in providing for fair equality of

opportunity. The special connection of nor-

mal functioning to opportunities for indi-

viduals is incorporated in the theories of

social, which provide a framework of liber-

ties and opportunities within which individ-

uals can use fair income-shares to pursue

their own conceptions of the good.

Equality of opportunity is highly impor-

tant. A person’s well-being will be mea-

sured for the most part by the primary

goods that accompany his/her functioning

in higher society. Rawls (1999) urged posi-

tive steps to be taken to enhance the oppor-

tunity of those disadvantaged by such social

factors as family background, race, and age.

The point is that none of us deserves the ad-

vantages conferred by accidents of birth,

neither the genetic or social advantages.

Based upon Rawls’ (1999) theory, then age

is morally arbitrary and to let age determine

individual opportunity is to confer arbitrari-

ness on the outcomes.

If properly adapted, a distributive justice

theory, such as Rawls’ (1999) theory, would

allow individuals from every community to

assume their equal share of the burden of

paying the cost of healthcare in an equitable

manner. This in return allows accessing

healthcare to become a special public good,

which is grounded in the basic principles of

justice. Furthermore, respect for persons

and their basic dignity is maintained

through communal action. An Egalitarian

Model of ethical practice recognizes the in-

dividuality of the aging and defines com-

mon community. Distributive justice can

have the greatest impact when applied to or-

ganizational decision making within a

healthcare organization.

organizational Decision making

The establishment of a national minimum

standard of care that distinguishes what an

adequate level of care should be for aging

persons, within a managed care organiza-

tion, would be a great leap in improving in-

adequacies within the healthcare delivery

system. Additionally, it would fill a void in

the lack of ethics within the healthcare sys-

tem. Justice means citizens have the right to

health protection, healthcare access, and to

live under healthy conditions (Rawls,

1999). Guaranteeing access and healthcare

resources is the basis from which frame-

works are built (Wonderling, Gruen, &

Black, 2005). Lacking a framework for

identifying and analyzing societal and orga-

nizational factors, representing the condi-

tions under which people are able to access

healthcare, concedes the absolute right to

health is unrealistic in our current health-

care system. This demonstrates the dynam-

ics of gate keeping ethics and that the

partnership between healthcare organiza-

tion, provider, and patient must be respected

through assuring distributive justice.

The establishment of fair and ethical pro-

cedures for the allocation of healthcare re-

sources is crucial within healthcare

management. If one looks at fairness based

upon the theory of distributive justice, there

are four conditions that define fairness. The

conditions are: (a) the public must have ac-

cessibility to limit setting decisions and the

rationale behind them, (b) there must be

clarity in the policies explaining the re-

source constraints and the value of money,

(c) there must be attempts for resolution of

disputes, and (d) a regulatory process must

provide an equitable mechanism for health-

care resource distribution (Darr, 1997;

Rawls, 1999; Rothbard, 1998). By follow-

ing these conditions a contemporary society

of healthcare providers, including nursing

professionals, can establish policies for

making decisions in regard to healthcare ra-

tioning.

When applying the principles of distribu-

tive justice to organizational decision mak-

ing within healthcare, the basic guiding

principle is fairness. Fairness means limit-

ing the discretion of administrative decision

makers, such as managerial boards and

health maintenance organizations, over the

care a physician or nurse will provide.

Principles of distributive justice argue that

only through deliberation within a democ-

racy can assumptions about aging, the value

of life for the aged, and intergenerational re-

sponsibilities of assisting the aging in their

care be set, tested, or rejected (Rawls,

1999). A fair democratic process allows the

average citizen to stay informed about their

healthcare choices and alternatives to

healthcare resource allocation.

When an organization attempts to adopt a

model for ethical distribution of healthcare

resources, it must be mindful that individu-

alism is not the sole basis for rights. Rather,

when combined with individual responsibil-

ities, individuals recognize responsibilities

to the community and engage with activism

to fulfill those obligations (Mill, 1871). It is

not unreasonable to ask individuals to as-

sume their fair share of the burden of

healthcare costs in an equitable manner. By

taking on equal costs, citizens maintain in-

dividual rights and healthcare is then seen

as a special public good (Brock, 2007;

Rawls, 1999).

By regulating the design of healthcare de-

livery, the equality of opportunity for all pa-

tients within the United States healthcare

delivery system is also protected. In order to

ensure this opportunity is open to all, an or-

ganization must adopt a model of just shar-

ing designed to equalize the financial costs

of illness. This model must recognize the fi-

nancial burdens of medical crisis and the

equal share of costs by sick and well alike.

Individuals cannot be expected to control

medical circumstances by their own choices

and freewill, therefore stressing the impor-

tance of cost sharing of medical expenses

(Dracopoulou, 1999).

In considering what model to use in limit-

ing the rise of healthcare costs, the model

should include aspects for respect of indi-

vidual autonomy, a patient’s ability to de-

cide what treatments he/she wants or does

not want, and the importance of reduction

Caring Enough to Provide Healthcare

2010, Vol. 14, No. 4 29

of cost expenditures (Kapp, 2001). Through

educating patients about options, they may

select options that are less invasive and less

expensive. Healthcare organizations that as-

sist individuals to deal with fear of death by

offering palliative options present cost-sav-

ing choices for both patients and healthcare

organizations (Johnson, 1999).

Establishment of hospital policies that in-

corporate mechanisms for resource alloca-

tions provide upfront ethical practices for

all providers. For example, hospitals that

have set standards for the use of Do Not

Resuscitate (DNR) orders eliminate deficits

through prolonged life of patients and have

providers who act ethically according to the

policy. These internal policies also provide

indicators for the type of patients for whom

specified services would be necessary. By

working with hospital ethics committees

and hospital boards, hospitals and providers

can help to eliminate unnecessary expenses,

claims of unfair treatment, and ultimately

malpractice suits (Mezey, Cassel, Bottrell,

Hyer, Howe, & Fulmer, 2002).

The use of an organizational decision

making model when determining the ethical

allocations of healthcare resources can

greatly aid nurses and nurse managers in

their work. Ethical dilemmas faced by nurse

professionals have involved conflicts

among principles, values, and professional

ethics and those of the organization in

which they practice (Armstrong, 2006).

Nurses are faced daily with ethical issues of

allocating services that include marketing,

admissions, transfers, discharges, billing,

and the relationships of the facility to other

providers and payers (Olsen, 2006). An es-

tablished organizational framework can re-

flect the ethical values that serve as a guide

for proper nursing behavior in allocation

decision making.

A healthcare organization cannot con-

sider itself one of noble purpose if its deliv-

ery of healthcare does not respect the

individuality of its patients (Stellard,

Decker, & Seller, 2002). Any organization

takes a gamble of dividing itself if it with-

holds care from the aging population on the

basis that return on investment cannot be

reached due to the limited lifespan of the el-

derly. The Rawls’ (1999) perspective of dis-

tributive justice would challenge a

healthcare organization to reallocate health-

care resources so that older persons are not

abandoned and balance is achieved in pro-

viding long-term health. Practitioners can

incorporate right, merit, need, and priority

of healthcare in their ethical framework for

determining and assisting patients with allo-

cation of resources.

Right

Everyone in the United States is entitled

to equal access and equal consideration of

healthcare, which is not a privilege to be ob-

tained or lost. Even those who are now in-

carcerated for criminal activity are given

equal access to healthcare. Thomas

Jefferson described equality as the “inherent

and inalienable rights” of life, liberty, and

the pursuit of happiness (Declaration of

Independence, 1776). Providing healthcare

to people, regardless of age, income, or

criminal record, is a basic value of humane-

ness. Rights are upheld by giving equal op-

portunity to every individual so that he or

she may have necessary provisions to

achieve and attain good health without re-

gard to capacity and ability to pay (Stellard

et al., 2002).

Merit

Merit is a valued judgment based upon

the basis of fitness and need. When deter-

mining one’s merit of healthcare the success

rate of the treatment has to be evaluated.

The meritorious use of a limited resource is

that which will yield the most successful

outcome (Blumenthal et al., 2003). Merit

examines the source of disease. A person

who contracts a disease or illness as a result

of a lifestyle choice, such as smoking or

risky behavior, may not have as high a merit

for treatment as someone who has health is-

sues as a result of genetic inequalities.

Individual personality differences such as

mental cognitive functioning, ability to pay,

insurance, and legal status all influence

merit of treatment as well (Stellard et al.,

2002).

Need

Need is based upon the evaluation of re-

quirements for the human condition (Coast,

2001). For example, cosmetic surgery to re-

pair the severe scaring of a burn victim

serves a far greater need than cosmetic

surgery for rhinoplasty. The severity of the

condition or disease greatly contributes to

the patient’s level of need. The most severe

and painful conditions receive preferential

treatment when delivering care (Halvorsen,

Førde, & Nortvedt, 2008). Urgency is also a

contributing factor when assessing need.

Lifespan, alternative treatment, and mainte-

nance of health all determine a patient’s ur-

gency for receiving care. For instance, a

patient with renal failure may not be seen as

urgent on the transplant list since his or her

health can be maintained through dialysis

(Russell, 2002).

Priority of Healthcare

In today’s management of medical prac-

tice there is virtually no guidance about the

priority of one patient group over another.

The weighing of patient groups’ priorities is

made especially difficult by the absence of

socially ranked healthcare benefits

(Johnson, 1999). Providers of healthcare for

older persons have very little to guide them

in ranking patient groups. This void of ethi-

cal guidance gives way to providers using

their own discretion when providing care,

which may mean that the wealthy receive

care before the impoverished or the young

get more care than the old.

In managed care settings, providers have

the daunting task of providing care for the

patient along with satisfying the well-being

of the financial stakeholders, including in-

surance companies, shareholders, etc. Fiscal

assets are required to run a healthcare orga-

nization. However, weighing possible treat-

ment actions in terms of financial gains or

losses is unethical. The financial benefits of

Caring Enough to Provide Healthcare

30 International Journal for Human Caring

stakeholders should not be the deciding fac-

tor in delivering healthcare to a patient

(Coast, 2001). Mezey and colleagues

(2002) showed that the priority is clearly

and always the patient. If the priority is in-

deed always the patient, then the monetary

gains of the organization must not outweigh

the patient’s health outcome. After all, a

healthcare organization exists for a purpose

and that purpose is to aid patients in need of

healthcare (Blumenthal et al., 2003).

Another priority in healthcare is respect-

ing the role of professional expertise in clin-

ical situations. Nurses and other

professional clinicians are designated by so-

ciety and licensure boards to make deci-

sions about diagnosis, prognosis, and

treatment. This in return creates an impor-

tant role for health professionals to deter-

mine what counts as health and what sort of

interventions will be beneficial to the pa-

tient (Ubel, 2008). Organizational decisions

should be made with collaborative expertise

of healthcare professionals as a priority.

Organizational decisions include staffing,

quality standards, utilizations standards,

and cost containment efforts; such decisions

affect healthcare providers and nurses to di-

rect the care of the patients appropriately

(Russell, 2002).

Summary

In summary, an organizational decision

making model for healthcare rationing must

incorporate two widely held judgments: that

there is something especially important

about healthcare and that some examples of

healthcare services are more important than

others. The philosophical task is to assess,

explain, and justify/modify distinctions

made about the importance of different

wants, interests, or needs. The recognition

and preservation of healthcare needs are im-

portant to maintain balanced human func-

tioning. In turn, such normal functioning is

an important determinant of the range of

opportunities open to an individual, regard-

less of age, gender, socioeconomic back-

ground, or race. The connection to

opportunity helps to clarify socially good

healthcare and provides the basis for health-

care institutions to function under principles

of distributive justice.

references

Armstrong, A. (2006). Toward a strong

virtue ethics for nursing practice. Nursing

Philosophy, 7, 110-124.

Blumenthal, D., Moon, M., & Warshawsky,

M. (2003). Long-term care and Medicare

policy: Can we improve the continuity of

care? Washington, DC: Brookings

Institution Press.

Brock. D.W. (2007). Health care resource

prioritization and rationing: Why is it so

difficult? Social Research, 74, 125-148.

Coast, J. (2001). Who wants to know if the

care is rationed? Views of citizens and

service informants. Health Expectations,

4, 243-252.

Darr, K. (1997). Ethics in health services

management (3rd ed.). Baltimore, MD:

Health Professions Press.

Dracopoulou, S. (1999). Ethics and values

in health care management. New York,

NY: Routledge.

Halvorsen, K., Førde, R., & Nortvedt, P.

(2008). Professional challenges in bed-

side rationing in intensive care. Nursing

Ethics, 15, 715-728.

Howe, E., & Lettieri, C.J. (1999). Health

care rationing in the aged. Drugs and

Aging, 15(1), 37-47.

Johnson, T. (1999). Handbook on ethical is-

sues in aging. West Port, CT:

Greenwood.

Kapp, M.B. (2001). Economic influences

on end-of-life care: Empirical evidence

and ethical speculation. Death Studies,

25, 251-263.

Mezey, C.K., Cassel, C.K., Bottrell, M.M.,

Hyer, K., Howe, J.L., & Fulmer, T.T.

(2002). Ethical patient care: A casebook

for geriatric health care teams.

Baltimore, MD: John Hopkins University

Press.

Mill, J.S. (1871). Utilitarianism (4th ed.).

London: Logmans, Green, & Dyer.

Olsen, D. (2006). Controversies in nursing

ethics: A historical review. Journal of

Advanced Nursing, 17(9), 1020-1027.

Rawls, J. (1999). A theory of justice.

Cambridge, MA: Belknap Press of

Harvard University Press.

Rothbard, M.N. (1998). The ethics of lib-

erty. New York, NY: New York

University Press.

Runciman, B., Merry, A., & Walton, M.

(2007). Safety and ethic in health care: A

guide to getting it right. Burlington, VT:

Ashgate Publishing Company.

Russel, B.J. (2002). Health care rationing:

Critical features: ordinary language, and

meaning. Journal of Law, Medicine, and

Ethics, 30, 82-87.

Stellard, J.M., Decker, I.M., & Seller, J.B.

(2002). Health care for the elderly: A so-

cial obligation. Nursing Forum, 37(2), 5-

15.

Ubel, P.A. (2008). Tough questions, even

harder answers. Journal of General

Internal Medicine, 17, 5-9.

Wonderling, D., Gruen, R., & Black, N.

(2005). Introduction to health economics.

New York, NY: Open University Press.

author note

Heather D. Craig, MPH, is a second-year doctoral student in the Health Service Program at Walden University, Minneapolis, Minnesota.

Correspondence concerning this article should be addressed to Heather D. Craig, 1080 Washington, Kansas City, MO 64105 USA.

Electronic mail can be sent via Internet to [email protected]

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