Chapter 3: The Moral Climate of Health Care

Section 3. Presentation of Issues

Clash of Values

In the institution and operation of health care there is a clash of values. The values of the social institution and free enterprise system often clash with the values of individuals for whom Welfare is a basic, a key value.

There is also the basic clash between the value of self interest and that of causing benefit to others.

ECONOMIC VALUES HUMANITARIAN VALUES
   
Social Institution Individual
Economy and Efficiency Freedom, Autonomy, Dignity, Privacy
Profit Health and Welfare
Advancing Knowledge and Technology Dignity and Comfort
   
   

Consider how the institutional values of economy and efficiency operate in the following case.

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Case:

A surgeon in Florida removed the wrong leg of a man he was treating. In the courtroom the President of the Florida

Association of Physicians testified that 90% of the doctors in Florida would have done the same thing! This was a statement for the defense.

The defense offered the typical method of operation for the hospital as an explanation for how the mistake could have occurred.

This defense presents the institution as functioning to promote efficiency and economy over the well being of the individuals it is ostensibly providing its services to benefit.

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The social value of the Health Care System is in its performance of several important social functions:

It provides health care to individuals. In so doing it provides employment to a significant portion of the population of the advanced technological societies.

It utilizes specialized knowledge and expands upon that knowledge.

At the same time that the health care system provides the value that it does it also has society pay a price for those services. It provides for health care and it is also responsible for many injuries to individuals through malpractice and causes tens of thousands of infections to individuals through various forms of viral and bacterial infection in its institutions. It causes death to tens of thousands of Americans through the wrong or medication or improper amounts of medications. Other deaths in the thousands are the result of a variety of forms of malpractice.

While many are employed by the health care system the cost of care constitutes a major factor in an increase in the cost of living and produces consequences elsewhere in the economy to exacerbate that increase.

While the health care system furthers our knowledge of disease and various techniques to further life and health at the same time medical research puts some humans at risk, causes injury to others and seriously compromises the moral practice of researchers who have responsibilities to treat those who come to them for assistance in the restoration of their health.

Even in providing for what value it does the institution of health care subjects human beings to an assault and a challenge due to the nature of institutions and bureaucracies.

Bureaucratic Model versus the Human Model

As in any large social institution with bureaucratic structures health care organizations function in a manner that often places the concerns of individuals after that of the organization itself. The apparent need to obtain insurance coverage information before rendering health care services even in an emergency room of a hospital is a manifestation of the placing of the organizational value before that of the individual, the assigning of bureaucratic values before human values.

In health care there is also a structure for command and control a hierarchy of control and authority that is often set against the decision making authority of the health care provider in contact with the recipient of the care and the decision making authority of the recipient of the services.

The large institution with the overbearing mass of its size and operations simply overwhelms the autonomy of the individual in far too many cases. Decisions concerning the welfare of individuals are removed from the individuals whose health and well being are at issue and at stake. Directly and indirectly the effective decision making often involves the recipient of the health care only marginally

Division of Labor with identifiable goals

There is in the institution of health care a sharp division in the roles played by its various constituent groups. The labors are clearly divided and responsibilities assigned. In so doing there often results situations in which there is no single person responsible or accountable for the ultimate outcomes.

A defense used in medical malpractice suits of late is that there was an institutional responsibility and no single person at fault when for example the wrong leg is amputated or the wrong drug is given to someone and it results in some harm, including death.

The whole organization of health care is to be blamed in the event of a claim of malpractice and no individuals are at fault. This might be termed the "It couldn't be helped " defense or the "You know how it is" response that accounts for the error by assigning responsibility

to the entire enterprise and its organizational structure rather than to specific individuals. So, while each person employed in health care has a specific role to play and can be held accountable for it there is no responsibility for the entire enterprise that can be assigned to any one person.

When the operation is performed on the wrong limb or the wrong person often each actor in the event claims that they did perform the assigned task that was assigned. " I was to remove the limb" "I was to anesthetize the patient" "I was to bring the patient to the OR" Where is the person who was to insure that it was the correct person and the correct limb? When the head of a medical society testifies that 90% of the surgeons in the state would have made the same mistake there is something very wrong and often what is wrong is the very structure of the organization.

In organizations with the structure of health care the values of industry, efficiency, predictability and speed are the highest values and they are quite impersonal and insensitive to the needs and feelings of human beings. This leads to the fundamental tension in situations in which many moral dilemmas arise. This tension can not be easily dismissed. Effective ways must be developed and institutionalized for the human concerns to be given an effective counter measure to that of the institution in order to minimize or avoid altogether some of the situations that give rise to moral problems.>>>Impersonal

The following factors contribute to some of the problems that arise within health care that often lead to some moral difficulty:
i. Non-routine tasks: respect for individuals versus routines and bureaucratic categories

ii. Internal dynamics: personalities, differing roles, differing authority, sex, age

iii. Conflicting values : institutions versus individuals

iv. Separation of patients from social context into institutional context: persons (human beings) become patients (social-institutional role)

v. Information Control- due to elitism and paternalism in the interest of maintaining a clear demarcation of roles and authority

vi. Communications Breakdown: a) amongst the health care providers and (b) between providers and recipients of care

vii. Dilution of Authority amongst health care providers and the system administrators

viii. Displacement of Authority from the recipient of care to the care providers to the institutional administrators

ix. Development of sub groups within health care with conflicting values, objectives and self interests

The clash in values evidences itself in the nature of the roles played by the providers and recipients of health care. A deeper look into those roles is next in order.

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Professions, Roles and Values

In the health care system many if not most of those who come into contact with the recipients consider themselves to be professionals and accept that they have a role as a professional to carry out. In the conceptions of those roles there are contained a host of assumptions and values concerning who they are and how they are to behave and to whom they are responsible that need to be exposed in order to gain a better understanding of how some situations arise and how the moral aspect of some situations are either ignored or dismissed rather than acknowledged and resolved in a more sensitive and thoughtful manner than is often the case.

Professional Model

There is a professional model of most of the roles in the health care system. Physicians, nurses, technicians, even the accountants and managers consider themselves to be members of a professions. The characteristics of a profession are:

Membership is based on formal educational achievement: degree, apprenticeship program etc...

A formal Recognition of membership- a licensing, certification

Professional Association with others of the organization, guild

A code of conduct created and monitored by members of the profession

Sanctions imposed by peers

With the Professional Model there proceeds a set of values as well. Principle among them are:

Autonomy-Members of a profession do not take kindly to those outside of the profession looking in on them let alone presuming to make judgments concerning their behavior or responsibilities. professionals cherish the idea that they are self motivating, self regulating and self controlled. They look after their own and take care of one another in the profession and the welfare of the entire profession is their concern and theirs alone.

Collegiality- Professionals recognize one another and feel solidarity with one another and think that they owe a loyalty to one another first even against the interests of those outside of their profession

Skill and knowledge- professionals place a very high value on the knowledge and skills that entitles one to membership in the profession. they so value such that those who possess them will be honored and protected by their fellow professionals even if those individuals may lack other human qualities or even if they bring harm to those outside of the profession.

Service to Others - Professional recognize that they provide a service to those outside of the profession but they tend to think that they do so as a matter of choice and not one of obligation. What the professionals provide for others is a matter of their choice to do so. They may deny their services to others if they so choose.

For physicians they enter the profession through formal education and licensing and they are self regulating. They educate one another throughout their careers. They do not take kindly to those outside of the profession examining or criticizing what they do. They tend to defend one another rather than to expose any member of the profession to critical or negative appraisals before the outside world. This they will do even when suspecting or knowing that one of their own has caused injury to a recipient of health care.

When a member of the profession runs up against a member of the bureaucracy the professionals support one another against the managers of the institution. If a surgeon wants a piece of equipment for a certain procedure and the administrator of the hospital denies the request due to cost the members of the guild might band together and take action or threaten to take action against the administrator. The highly skilled surgeon might move the practice to another hospital taking the reputation of the practice and the clients that it attracts along with the surgeon to the other hospital that has or is willing to supply the desired equipment. In this clash the value of proficiency with the surgical skills and the furthering of knowledge and success in treatment is place above economy and efficiency. The professionals are likely to win in such a clash because their threat is directly against economy and profit.

In like manner professionals will resist decisions not in their interest made by bureaucrats without the skills and knowledge and experience of one of their own members. Medical institutions will prefer to give positions of authority to physicians in order to preserve the respect for authority from members of the medical professional. Hospital administrators who are not physicians but are business managers, lawyers and accountants will have less respect from remembers of the medical profession and be resisted more often when decisions are not in keeping with the values of the profession.

This tension is also in evidence concerning treatments to be given when the treatment preferred by the physician is not covered by the medical insurance organization. The administrator is concerned with the welfare of the institution and its ability to reclaim assets expended in rendering care. The physician is concerned about employing the latest knowledge and skill towards the alleviation of the physical problem.

What does being a member of a profession mean?  Here is one set of answers prepared for physicians in training:

For the answers: READ : http://depts.washington.edu/bioethx/topics/profes.html

Professional Model clashes with the Bureaucratic Model> Tensions

Professional Model

Bureaucratic Model

Medical Administrative Line of Authority
Service Economic Good
Specialized labor Flexibility
Authority based on expertise Authority based upon Position
   

Case

At Downstate Medical College, SUNY, in Brooklyn a faculty member teaches a portion of the psychiatric unit.

I once spoke with her about hopes that as more medical schools admitted more people of color and females there would be a humanizing result. I thought that people previously excluded and who are from groups often victimized there would be an increased sensitivity to those they would be helping. She informed me that the competition to get into medical school appears to favor the insensitive. Female entering the medical school had a good deal of machismo. They needed it to survive and to win a spot.

Further, she said that she did not think that the medical institution would be sensitized anytime soon. She told me of this brilliant surgeon on the staff of the hospital whose reputation was great and who rose quickly to a high position and who had much status. He would be called for a consult and even to perform procedures. He would tell the other physician who would call him in that he would do the procedure as long as he did not need to talk to the person who was to receive the procedure. He admitted that he was not good with communications skills and did not like talking to people , least of all , those he helped. Well the colleagues so admired his skills that they accepted his terms. The head surgeon at the hospital told my friend: "He is a son of a bitch but if I ever needed a heart operation there are no other hands that I would want working on me. He has some pair of hands."

Well, here is a story that illustrates the value of PROFICIENCY above almost all else.

In this story I think the person who suffers the most is the gifted surgeon who is reduced to "a pair of hands." The day will come , perhaps even "days", when we and he will pay the price for that dehumanizing that has occurred.

Case

IDEALIZED EXPECTATION

Some year ago there was a TV show on the ABC network titled: MARCUS WELBY, MD.  It was a hit show and had a large audience and high ratings.

The AMA and other groups of doctors protested against the show and requested that the network cancel it! Their complaint was that the show built up expectations in the public for their own doctors treating them as Doctor Welby was treating the people he saw on the show each week. They said that the show portrayed the doctor as personable and caring and spending time talking to and getting to know those he treated and being there for them and even VISITING THEM AT HOME!!!

The AMA protested that this cannot be done in most cases.  Physicians have many people that they need to see and a need to produce a large income flow in order to pay off their student loans and staff and other expenses , no to mention the maintenance of a life style they expect to enjoy.

Clearly there was a clash here between the public and its expectation that human values would be respected and the profession of medicine, represented by the AMA, and its felt need to honor the institutional values of efficiency and economy.

Role Conflicts

As members of the professions any clash with the bureaucrats they may also clash amongst themselves. Members of the different professions have different roles and often have different expectations concerning outcomes.

There are at times even incompatible expectations and values. Take for example the very popular clash between physicians and nurses.

This clash arises between the role of Physician and that of the Nurse due to a number of differences, including:

1. educational status

2. career patterns

3. semantic differences

4. class differences

5. authority differences

6. sex differences

7. different orientations: care versus cure

8. different amounts of time with recipients of care

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Case:

A well educated and lucid fifty five year old professional woman has reached the point of having her ovarian cancer metastasized. Over the course of 11 months of treatments she has filed out a proxy form and a living will

and has expressed to her nurse several times her desire to halt treatment of any kind should she experience another respiratory arrest. Nevertheless, a physician is called when the arrest occurs and proceeds to intubate and respirate over the nurses objections.

The nurse in the role of patient advocate is representing the desires , values and legal rights of the recipient of health care. The young physician on call has entered the situation with a desire to further develop skills and knowledge and experience and arrest the

course of the disease if only temporarily. The nurse has as the expectation a CARE for the person receiving it. The physician is oriented towards a CURE.

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Roles , Values , Treatments and Moral Concerns

As there can be a clash amongst the professionals and between professionals and the administrators there are also and more pointedly clashes that occur between the providers of health care and the recipients. Next in order here is an examination of the conception and role of the recipient of health care , called most widely, the PATIENT

As the patient is a human being , possessed of human rights and carrying human values and moral concerns how that person is viewed within health care can share a good deal of light on how the person is treated and the moral problems that sometimes result.

 

"Patients, Know Your Rights "

Sunday, February 24, 2002 PARADE Magazine Article

Dr. Isadore Rosenfeld ' advice:

1. You have a right to select your doctor.

2. You have the right to be fully informed about your health status.

3. You have a right to a second opinion.

4. You have a right to preventive medicine.

5. You have a right to know your surgeon's and hospital's track record for the procedure you need.

6. You have a right to know about financial relationship between your doctor and your insurance provider.

7. You have a right to a rapid medical-review process.

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December 2, 2008

The Six Habits of Highly Respectful Physicians

By MICHAEL W. KAHN, M.D

Recently, I asked a colleague about the quality of care her hospitalized mother was getting. "Well, you can at least have a conversation with her doctor," she replied. Clearly this was a big relief.

High-level skills like reflectiveness and empathy are an important part of medical education these days. That is all to the good, of course. But as I noted last May in an article in The New England Journal of Medicine, medical schools may be underemphasizing a much simpler virtue: good manners.

In the article, I described a common-sense method for spreading clinical courtesy that I call "etiquette-based medicine," and I proposed a simple six-step checklist for doctors to follow when meeting a hospitalized patient for the first time:

• Ask permission to enter the room; wait for an answer.

• Introduce yourself; show your ID badge.

• Shake hands.

• Sit down. Smile if appropriate.

• Explain your role on the health care team.

• Ask how the patient feels about being in the hospital.

Do doctors really need to be told to do such obvious things? Unfortunately, anyone who has spent time in the hospital as a patient or a physician knows how haphazardly such actions are performed, and as Samuel Johnson wrote, "Man needs more to be reminded than instructed."

There is a useful analogy here to raising children. The British physician D. W. Winnicott coined the term "good enough mother" in part to help mothers who were overly anxious about their parenting skills. Rather than worry about trying to be perfect (whatever that meant), he urged them to relax, trust their intuition and realize that their children needed a mother who was caring, alert and reliable — in other words, good enough.

Similarly, when medical schools try to turn out ideal doctors, they can miss the opportunity to help them be good enough: perhaps not perfectly attuned to the patient, but at least respectful and professional. An etiquette-based approach can promote such behavior.

Etiquette-based medicine rests on the fact that patients derive comfort from specific actions — as opposed to attitudes or feelings — that are independent of the doctor’s emotional investment in the patient. My doctor may be tired, preoccupied or not that interested in me as a person; but I should still expect him or her to treat me with the kind of attentiveness and respect I recently received from a "genius" at the local Apple store.

The "genius" was skillful, efficient and professional, and solved my problem quickly without feeling my pain (which had been considerable). I don’t necessarily want or need to have an exceptional healer, but I would like to have good service. Patients should command at least the same regard from their doctors.

Does this mean surrendering medicine’s nobler values in the service of mere client satisfaction? Not at all. Consider one more analogy: A developing country may make a major investment in M.R.I. machines, an essential element of up-to-date medicine. But that money will be misspent if the country lacks enough antibiotics and doctors to prescribe them.

By the same token, trying to cultivate deeper human sensibility in doctors will be an inefficient use of scarce educational resources if those doctors cannot make the time to sit down, introduce themselves and make eye contact with their patients. Training good enough doctors should be like fluoridating the water supply or vaccinating children: uncomplicated, routine, relatively inexpensive — but with widespread and long-lasting benefits.

Michael W. Kahn is a psychiatrist in Boston.

Copyright 2008 The New York Times Company

There have been efforts to sensitize health care providers in the various professions to the human beings they care for and their human concerns. There is even an effort to test for certain skills.

READ: Test for Doctors

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© Copyright Philip A. Pecorino 2002. All Rights reserved.

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