FOR PROF.MACQUEEN ONLY (10)
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hsa500_w10_c15_1.pptHealth Services Organization and Management
HSA 500
Ethical Issues in Public Health and Health Services
Williams, S. J., & Torrens, P. R. (2008). Introduction to Health Services (7th ed.). New York: Cengage Delmar Learning.
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Welcome to Health Services Organization and Management.
In this lesson we will discuss ethical issues in public health and health services.
Please go to the next slide.
Objectives
- Upon completion of this lesson, you will be able to:
- Explain the impact that policy, social and financial forces have on health care access and quality of care in the United States
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Upon completion of this lesson, you will be able to:
Explain the impact that policy, social and financial forces have on health care access and quality of care in the United States.
Please go to the next slide.
Public Health
- Provision of care
- Equity in distribution of resources
- Respect for human rights
- Role of law
Public health ethics evokes a number of dilemmas, many of which may be resolved in several ways, depending on one’s standards and values. Data and evidence are relevant to the normative choices involved in public health ethics.
We argue for these assumptions of a public health ethic:
- Provision of care on the basis of health need, without regard to race, religion, gender, sexual orientation, or ability to pay;
- Equity in distribution of resources, giving due regard to vulnerable groups in the population; and
- Respect for human rights – including autonomy.
Central to the solution of ethical problems in health services is the role of law, which sets forth the legislative, regulatory, and judicial controls of society. The development of law in a particular field narrows the discretion of providers in making ethical judgments. At the same time, law sets guidelines for determining policy on specific issues or in individual cases.
Please go to the next slide.
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Ethical Issues in Developing Resources
- The numbers and kinds of personnel required and their distribution are critical to public health
- Principle of autonomy
- Research is central to developing public health resources
When we talk about developing resources, we mean health personnel, facilities, drugs and equipment, and knowledge. Choices among the kinds of personnel trained, the facilities made available, and the commodities produced are not neutral. Producing and acquiring each of these involve ethical assumptions, and they in turn have public health consequences.
The numbers and kinds of personnel required and their distribution are critical to public health.
The principle of autonomy urges that resource development be diverse enough to permit consumers some choice of providers and facilities.
Research is central to developing public health resources. Equity mandates a fair distribution of research resources among the various diseases that affect the public’s health because research is costly, resources are limited, and choices have to be made. Research needs both basic and applied orientation to assure quality. There is a need for research on matters that have been neglected in the past, as has been recognized in the field of women’s health.
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Ethical Issues in Developing Resources, continued
- Ethical implications
- Biomedical research
- Conflict of interest with scientists
- Policy makers
- Protecting public health and protecting the rights of individual patients
Ethical implications involving privacy, informed consent, and equity affect targeted research grants for AIDS, breast cancer, and other special diseases.
Federal law in the United States governs conduct of biomedical research involving human subjects. Ethical issues are handled by ethics advisory boards, convened to advise the Department of Health and Human Services on the ethics of biomedical or behavioral research projects, and by institutional review boards of research institutions seeking funding of research proposals.
An overarching problem is the conflict of interest of scientists who are judging the effectiveness of treatments and drugs and, at the same time, may be employed by or serving as consultants to a pharmaceutical or biotechnology firm.
Correction of fraud in science and the rights of subjects are important ethical considerations in developing knowledge.
Policy makers concerned with developing resources for health care thus confront tensions between protecting public health and protecting the rights of individual patients and providers. They face issues concerning allocation of scarce resources and use of expensive medical technology.
We trust that in resolving these issues their decisions are guided by principles of autonomy, beneficence, and justice as applied to the health of populations.
Please go to the next slide.
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Check Your Understanding
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Ethical Issues in Economic Support
- Personal autonomy
- Financial barriers exist
- Social Security and Medicare
- Society has an obligation to assure equitable access to health care for all its citizens
Nowhere is the public health ethical perspective clearer than on issues of economic support. Personal autonomy and respect for privacy remain essential, as does beneficence. But a public health orientation suggests that the welfare of society merits close regard for justice.
From the public health perspective, financial barriers to essential health care are inappropriate. Yet they exist to a surprising degree.
Institutions such as Social Security and Medicare play a moral role in a democracy. They were established to attain common aims and are fair in that they follow agreed-upon rules. Proposals to privatize them undermine these goals.
Social solidarity between the young and the elderly are critical. As members of a society made up of overlapping communities, our lives are intricately linked together.
In 1983, the President’s Commission for the Study of Ethical problems in Medicine and Biomedical and Behavioral Research made as its first and principal recommendation on ethics in medicine that society has an obligation to assure equitable access to health care for all its citizens.
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Ethical Issues in Organization of Services
- The principal ethical imperative
- Services be organized and distributed in accordance with health needs and the ability to benefit
- To be fair and just, a health system must minimize geographic inequity in distributing care
The principal ethical imperative in organization of health services is that services be organized and distributed in accordance with health needs and the ability to benefit. The problem with rationing on the basis of ability to pay is that it encourages the opposite. The issues of geographic and cultural access also illustrate this ethical principle.
To be fair and just, a health system must minimize geographic inequity in distributing care. Rural areas are underserved, as are inner cities.
The principles of autonomy and beneficence require health services to be culturally relevant to the populations they are designed to serve. This means that medical care professionals need to be able to communicate in the language of those they serve and to understand the cultural preferences of those for whom they seek to provide care. The probability of success is enhanced if needed health professionals are from the same cultural background as those they serve. This suggests that schools of medicine, nursing, dentistry, and public health should intensify their efforts to reach out and extend educational and training opportunities to qualified and interested members of such populations. To carry out such programs, however, these schools must have the economic resources required to offer fellowships and teaching assistant positions.
Please go to the next slide.
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Ethical Issues in Management of Health Services
- All activities that involve ethical choices:
- Organization
- Staffing
- Budgeting
- Supervision
- Consultation
- Procurement and Logistics
- Records and reporting
- Coordination
- Evaluation
- Distribution of scarce health resources
Health administration has ethical consequences that may be overlooked because they appear ethically neutral: organization, staffing, budgeting, supervision, consultation, procurement, logistics, records and reporting, coordination, and evaluation. But all these activities involve ethical choices.
Distribution of scarce health resources is another subject of debate. The principle of first come, first served may initially seem equitable. But it also incorporates the “rule of rescue” whereby a few lives are saved at great cost, and this policy results in the “invisible” loss of many more lives. The cost-benefit or cost-effectiveness analysis of health economics attempts to apply hard data to administrative decisions.
Please go to the next slide.
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Ethical Issues in Delivery of Care
- Resource allocation
- Rationing
- Organ transplants
- Mandatory donation
We will now discuss delivery of care. Resource allocation in a time of cost containment inevitably involves rationing. At first blush, rationing by ability to pay may appear natural, neutral, and inevitable, but the ethical dimensions for delivery of care may be overlooked. If ability to pay is recognized as a form of rationing, the question of its justice is immediately apparent.
Rationing medical care is not always ethically dubious. In some cases, too much medical care is counterproductive and may produce more harm than good.
Rationing organ transplants, similarly, is a matter of significant ethical debate because fewer organs are available for transplant than needed for the 85,000 people on waiting lists.
One solution would be to make more organs available through mandatory donation from fatal automobile accidents, without explicit consent of individuals and families. Spain leads other nations regarding organ donation.
Please go to the next slide.
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Ethical Issues in Delivery of Care, continued
- The practice of medicine and public health screening
- Provide care for those found to be affected
- Ethical principles of beneficence and social justice
The practice of medicine and public health screening presents serious ethical dilemmas. Screening for diseases for which there is no treatment, except where such information can be used to postpone onset or prevent widespread population infection, is difficult to justify unless the information is explicitly desired by the patient for personal reasons.
Public health providers need to be sure in advance that they can offer the health services required to provide care for those found to be affected. These are the ethical principles of beneficence and social justice.
Please go to the next slide.
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Check Your Understanding
4.unknown
Summary
- Public Health
- Ethical issues in developing resources
- Ethical issues in economic support
- Ethical issues in organization of services
- Ethical issues in management of Health Services
- Ethical issues in delivery of care
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We have reached the end of this lesson. Let’s take a look at what we have covered.
Discussed first was public health and ethics. We argue for these assumptions of a public health ethic:
Provision of care on the basis of health need, without regard to race, religion, gender, sexual orientation, or ability to pay;
Equity in distribution of resources, giving due regard to vulnerable groups in the population; and
Respect for human rights – including autonomy.
Next we discussed Ethical Issues in Developing Resource. The numbers and kinds of personnel required and their distribution are critical to public health. The principle of autonomy urges that resource development be diverse enough to permit consumers some choice of providers and facilities. Research is central to developing public health resources. Equity mandates a fair distribution of research resources among the various diseases that affect the public’s health because research is costly, resources are limited, and choices have to be made.
Next we discussed Ethical Issues in Economic Support. From the public health perspective, financial barriers to essential health care are inappropriate. Yet they exist to a surprising degree.
Next we discussed Ethical Issues in Organization of Services. The principal ethical imperative in organization of health services is that services be organized and distributed in accordance with health needs and the ability to benefit. To be fair and just, a health system must minimize geographic inequity in distributing care. Rural areas are underserved, as are inner cities.
Next we discussed Ethical Issues in in Management of Health Services. Health administration has ethical consequences that may be overlooked because they appear ethically neutral: organization, staffing, budgeting, supervision, consultation, procurement, logistics, records and reporting, coordination, and evaluation. But all these activities involve ethical choices.
We concluded the lesson with examining Ethical Issues in Delivery of Care. Public health providers need to be sure in advance that they can offer the health services required to provide care for those found to be affected. These are the ethical principles of beneficence and social justice.
This concludes this lesson.
