Diminishing resources, critical choices

...It would be a serious error to lay blame solely or even mainly at the feet of health care managers...

...that this power must come to terms with the question of the allocation of resources, the use of technology, and the meaning of institutional survival...

...The defense of these practices is always the same — otherwise the hospital would not be able to treat anyone...

...But unless hospitals as a group, and society as a whole, deal with obesity, tobacco, alcohol, insufficient exercise, environmental pollutants, carcinogenic industries, etc., we will forever be cleaning up bigger and bigger messes, probably with bigger and bigger technology...

...Or, if this covert action is politically impossible, it can mean limiting the number of times per month or per year that an individual may be seen in clinic regardless of the diagnosis...

...They are partly made, like the blind men's description of the elephant, without consciousness of the whole...

...The trade-offs between acute care and public health must be understood and acted upon at both the institutional and societal levels...

...The role of the health care administrator is seen as adjunct: balancing the budget, dealing with labor strikes, involving and placating both the local community and the Board of Trustees...

...The decision to manage matters dealing with health, sickness, and death is a vocational decision, a statement of mission...

...And as hospitals became big business, full-time administrators trained in business methods were hired to run them...

...Now technology can keep them alive...

...Those dollars would be spent in hospitals, for acute and critical care, rather than in preventive and/or non-hospital projects, and would require an even larger administrative staff to manage them...

...I have no quarrel with what was going on in that unit — there was dedicated, brutally hard work apparent everywhere...

...What standard are they being instructed to follow by the larger society and/or its constituent groups...

...Sometimes its goals include cheating death for a while...

...However, when the Medicare and Medicaid legislation of the mid-sixties went into effect, the whole face of health financing and administration changed...

...I would like to think that at this juncture my premise is clear: health care administrators are as deeply involved with ethical questions as medical personnel...

...Significantly, insurers began paying money directly to hospitals through administration, though some payments continued directly to physicians...

...Several "million dollar babies" were pointed out to me: infants and children who could not be weaned off respirators and/or other equipment — children two-years-old whose parents had not visited for twenty months — who could not be referred anywhere more conducive to the normal development of a child because no other place in that city had the requisite technologyAs our society rushes to build more intensive care units, we notice, with great dismay, that our medical costs are rising far above our other costs, that they seem uncontrollable...

...2) paradoxically, it has been well understood by most physicians who fully grasp the degree to which they are controlled by bureaucratic regulations, however much they resent it...

...The obvious problem is that as fewer resources are available, it becomes more difficult to decide how best to use them...

...In the neonatology intensive care unit around the baby boy were heavy concentrations of skilled medical personnel and extraordinarily expensive equipment and supplies...

...Commonweal: 140 There is one other general principle: the health of the individual and the health of the group will sometimes come into conflict...

...If reason and compassion are to return to health care decisions, then health care administrators must play a major role in forming policy in their institutions...

...It means "de-marketing," a new and creative use of language in health administration...

...Moon shots, nuclear energy, and medical technology all fall under this rubric...

...A large urban teaching hospital which thought of itself as a big business with a budget of $20 million in 1965, had a budget of $180 million by 1980...

...TWO EXAMPLES, may make the point clearer...

...Consequently, there is an urgent, severe need to develop an ethics of hospital administration...

...It is a calling, as such things are, to serve...

...The ethical issues in health administration are the allocation of resources and the uses of technology (including a true understanding of what that use may mean...

...The total number of patient care days in a given period was divided into total cost, and, presto, that became the daily rate at which the hospital was reimbursed for each patient day for the next eighteen months, a retrospective cost system...

...The law is now sufficiently open-ended to allow physicians, administrators, trustees, and hospitals to be sued for murder and/or assisted suicide if they fail to resuscitate unconscious, vegetative patients...

...Neither society nor the health care administrator is aware of the truly overwhelming ethical content of these decisions...

...Learning good business techniques is necessary if one is setting out to run a hospital...

...On another level, once Medicaid officials have made an open-ended commitment to reimburse neonatology intensive care units, rather than prenatal screening and nutrition, it is not hard to predict what kind of health care patterns we will be seeing...

...Now these unwanted patients were paying customers, and payment for them went straight to the hospitals, not the physicians, except for specific physician services...

...I worked in a hospital where the wing in which abortions were 8 March 1985: 139 done and the wing in which the neonatology intensive care unit was located, were on the same floor...

...The health administrator should make his or her decisions cognizant of the need for institutional survival and patient treatment, but also for the general health of the community...

...They are not actors, but reactors, and willingly or not, perpetuate a frequently unequal, chaotic method of providing health care...

...The same considerations hold for resource allocation...

...Obviously, there is a need to develop an ethics of health care administration...

...This is not necessarily negative — hospitals until quite recently were looked upon as a social good...

...They formed powerful professional organizations and lobbies which generated financial dena seiden, a doctoral candidate in ethics at Union Theological Seminary, teaches ethics of health care organizations at Columbia University School of Public Health and is a former health care administrator...

...Physicians defined who was sick and who was healthy...

...The Hippocratic Oath meant for physicians has come under justified criticism recently for its insistence that the physician do what is best for the patient without consulting anyone, including the patient...

...The first step in the creation of an ethic of health care administration is to reject this idea as mistaken and to assert that institutions serve people, not the other way round...

...Meanwhile, and this is the point, administrators of health care deal with these issues daily...

...They are influenced by the frustration of trying to reach people outside the usual health care system, and by the realization that they will bring no personal advancement or political gain to the individual administrator...

...to rethink our definitions of life and death...

...The administrator, located behind two secretaries and a receptionist, can easily imagine that she or he is working for the "good of the institution" and rest content...

...The Baby Doe case (1982) brought to national attention the issue of whether parents and physicians could withhold lifesaving treatment from their retarded newborn child...

...What resources, what technology will society, through the decisions of the health care system, devote to keeping alive those who would have died naturally a few years ago...

...But two separate sets of issues are raised with great urgency...

...Or, even more subtly, it can be done by making the patient wait several months for an appointment, and then wait eight or more hours on the day of the appointment so that a truly sick person, a marginally employed person, a mother with several children at home will be discouraged from seeking treatment...

...Until quite recently, children born under two pounds died...

...Its goals are to maximally prolong the functioning and wellness of the population and to optimally treat, and if possible cure, sickness in the individual and community...

...The second example, because it involves policy-making, goes beyond merely administrative decisions to societal ones...

...The figure given to me in that county hospital was $ 1,500 per patient day...

...which supplies solid nutrition for pre-and post-natal mothers and children, thereby insuring ourselves a new crop of candidates for neonatology intensive care units...

...The fee-for-service system of payment made physicians successful individual entrepreneurs, dependent on no one for outside funding...

...The boy died before the issue could be settled in court where suit had been brought...

...The administrator takes the role of the advocate of society's health...

...8 March 1985: 137 Medicaid and Medicare payments were built on hospital costs...

...At a large county hospital, I saw and reviewed the records of a day-old male baby, born at one pound, twelve ounces and immediately rushed to the neonatology intensive care unit...

...The about-face described above is of recent origin...

...The government was guaranteeing payment for patients who had previously been charity cases...

...As the stories in the media, and as daily life makes plain, this is a problem of even greater severity among older patients...

...This view raises institution above people, a depressingly common experience in history and at the present time...

...And it is done in the name of the institution, so that the institution can survive, grow, prosper...

...Providing health care is one of the more specific activities of life...

...De-marketing" means making an administrative decision to "dump" uninsured or not well-insured, chronically ill, older, lower-class citizens...

...The unasked question is whether such a price for institutional survival is acceptable...

...This fact is remarkable on several counts: (1) it has not been appreciated by the general community...

...Every chief executive officer should be responsible for initiating and/or implementing policies for (a) resuscitation of the unconscious...

...These practices are, if not sanctioned, at least tolerated by society at large...

...systems that guaranteed physicians' wealth and independence...

...What are we not doing with that money...

...PRESCRIPTION FOR A MEDICAL ETHIC Diminishing resources, critical choices DENA SEIDEN OUR SOCIETY sustains the myth that physicians, and occasionally nurses, make life and death decisions for us and control the degree of health and sickness...

...sometimes its goals are to ease death...

...The mother arrived at the hospital in labor, claiming heroin addiction and asking for intravenous methadone to stave off withdrawal pains...

...The central point, though, is that the qualities valued in hospital administrators have not been devotion to the common good: in this case, the health of the populace and the cure of the sick...

...They are made by health care administrators at all levels...

...The mission of hospitals then is tied to the above definition, and can also reasonably include teaching professionals and nonprofessionals skills which are designed to promote health and combat sickness...

...Commonweal: 138 However, the underlying questions, for administrators and for society as a whole, about the societal resources consumed by these children and what the use of technology could accomplish in securing even minimally functional lives for them were not well-surfaced in the hubbub surrounding either of these cases...

...The Baby Jane Doe case raised the same issues (1983) plus the question of society's right, acting through the executive and judicial arms of the government in this case, to remove the issue from the sole jurisdiction of parents and physicians into itself...

...If there is none, shouldn't there be...

...In the abortion wing, there were sometimes live healthy infants, fully formed, perfectly viable...

...But there is an enormous cost to such use of technology far beyond the direct cost of the machinery and labor...

...The questions are clear — the allocation of resources, the use of technology, the meaning of health institutions — and are now decided by administrators...

...Physicians and nurses still make immediate decisions on patient care that have implications for life and death...

...In consequence, major decisions are made as though they have no ethical content, and thus often have unlooked-for, negative consequences for the population...

...Such efforts may fail with individual mothers, but can anyone think they would fail with the majority of mothers who badly want a healthy child but who may not know how to produce one...

...For instance, once a hospital has decided to build a neonatology intensive care unit, it has already so skewed its resources that a large commitment to prenatal nutrition and screening may not be possible...

...The second set of issues raised by the case of the hy-drocephalic premature boy pertains to the absence of any parallel concentration of labor and equipment that might prevent certain tragedies from recurring...

...On the one side, the viable, who would die...

...This in turn gave them considerable control in these institutions...

...The mother in this case cannot be presumed to have wanted harm for her child, but she may well have been unable to prevent that harm...

...What is of interest to us is that these changes in financing medical care turned hospitals into big business...

...The schools of hospital administration were often placed in the business schools of a university or offered joint degrees in business administration and finance administration along with their degrees in hospital administration and public health...

...The former are involved on a broader, social scale, but their decisions affect life and health every bit as much as those of medical personnel...

...As a society, we are conditioned to the technological fix — if we can do something, then we should do it, no matter the cost...

...Research is included for the promotion of health and defeat of illness, though the path may be more indirect...

...It is primarily health care administrators who make this type of decision, not physicians...

...But who gets care, when, where, how much, of what quality, and with what technology is, for the most part, no longer determined by clinical personnel...

...Thus the system was controlled by its practitioners...

...Nor do I offer any definitive opinion on whether that child should have been rushed to intensive care...

...There is a question here that challenges the way in which life and death are perceived and dealt with...

...c) aggressive treatment of the terminally ill...

...Through the political, judicial, and information-dispensing mechanisms of society, we all must work out what is an acceptable health system, even as health technology is forcing us...

...The industry has grown from 7.2 percent of the GNP in 1970 to 10.7 percent in 1984, and continues to inspire aggressive management...

...But one sentence within the Oath is useful ais a grounding for health care ethics, if provision is made for the contractual nature of the relationship between the patient, the physician, and the administrator: "The regimen I adopt shall be for the benefit of my patients according to my ability and judgment and not for their hurt or any wrong...

...From the mid-nineteenth century on, physicians successfully put energy into controlling their environment...

...that power has an inevitable ethical component...

...The Baby Doe case had caused a furor by limiting the right to only physician and parent...

...A brief reading of the medical chart left several questions unanswered: the mother's wishes, the delivering physician's best judgment on viability...

...This should begin with the idea of mission: facilitating health and combating sickness...

...And on the other, the sick, who at great expense, might live, but might also have a painful, prolonged death in an alien environment...

...The hospital can then switch its resources back to marketing the desirable group...

...Who has the right to make a decision to withhold treatment...

...Administrators of the system, in hospitals, health bureaucracies, profit-making hospital chains, and drug companies are all largely working from the same ideology: the "bottom line" is to operate in the black...

...The admired executive is the one who enlarges the system, who "gets ahead...

...The profession should be radicalized, neither to the left nor right, but to a consideration of the administrator as rational actor, not blind reactor...

...The fact that there is no discipline, no body of literature on the ethics of health care administration, is a call for it to be produced...

...That is, hospitals must have .the tools to treat heart attack and trauma victims, remove gall bladders, insert artificial hips...

...The next step would be to orient the profession to the fact that health care administrators have power...

...Practically, it means rearranging clinic fees to a level so that the latter group can no longer afford the services of that hospital...

...Where is the hospital, multiinstitutional, private, or governmental program that will attempt to find such high-risk mothers and, with acknowledged difficulty, deliver prenatal health care, screening, and nutrition...

...And at what cost to those now alive and those yet to come...

...The first set concerns the necessity of every single health care institution to set some guidelines, to have some ethics board that sets policy and hears disputes in individual cases to prevent either the automatic extension of extraordinary measures to prolong life or, conversely, to withdraw life-sustaining treatment...

...The spread of insurance, the gaining strength of the hospital labor unions, the explosion of new technologies — all these contributed to rising health care costs and the rising power of a managerial class...

...The boy was hyd-rocephalic, as well as premature at twenty-six weeks...

...Indeed, it often made them the major source of funding for the hospitals in which they practiced...

...Rather, it is determined by administrators in individual hospitals, governmental and semi-public agencies...

...In fact, those roles began to change twenty years ago and are now invalid...

...Marketing" in health has always meant getting your hospital involved with well-insured, not chronically ill, largely younger and middle-class citizens...

...In the large urban and suburban teaching hospitals, these patients were generally cared for by house staff (interns and residents) who were members of the salaried labor force of the hospitals for which the hospital then received payment...

...Examples of resource problems might include an individual hospital's commitment to a large new renal dialysis program at the expense of cutting space, staff, and equipment for geriatrics or, conversely, a reassessment of the effect of open-ended Medicare financing on provision of care to younger sectors of society...

...This allows all concerned — the staff, the patients, the public — to have the same understanding of what a given hospital's policy is...

...With this in mind, a beginning framework for ethical administrative decision-making might include: • Every technology must be weighed for its direct and indirect costs, its direct and indirect benefits and harms, before being pursued...

...This assertion can then form the beginning of an ethic of health care administration...

...It is mistaken...

...The New England Journal of Medicine in August, 1981 and Pediatrics in June, 1978 estimated the average cost of a stay in a neonatology intensive care unit from $14,000 to $88,000 depending on the ensuing complications...

...Both think the decisions are financial, managerial, and "housekeeping" functions...

...The less obvious problem is that the changes place even greater power in administrative hands (for reasons beyond the scope of this article) and it will be administrators more than physicians who decide how long patients stay in hospitals, in what setting they are treated, what types of cases are "acceptable," and so on...

...What an incentive this was to pile on more and more cost — build new wings, new buildings, hire more staff, and most particularly, hire more house officers to take care of ever more Medicaid and Medicare patients, and so the expansion cycle continued...

...So we allow the government to cut back, among other things, die Women and Infant Children program (W.I.C...

...These are decisions in which the ethical component could hardly be more striking...

...Implicit in this is an emphasis on mission — to serve the goals of patient care and sickness prevention...

...These two issues often come together, each enlarging the questions of the other, each impinging on the question: what price survival...

...It did mean, however, that society was pledged to spend its health dollars in certain ways...

...Lobbies drew on the beliefs and perceptions , already apparent in the community, that physicians were beyond law, politics, and ordinary finance — a sacred group to and for the culture...

...A clear example, for which the daily press highlights the need, is the necessity for a hospital policy on patients with permanent loss of consciousness and/or who are in a persistent vegetative state...

...4) it leaves administrators who are trained only in "business" skills such as budgeting, staffing, reimbursement, etc., to make decisions of immense ethical significance for which they have no training, hence no framework within which they can place these decisions...

...In the neonatology unit were desperately sick infants with multiple anomalies and with tubes and lines inserted so they could live...

...Every single health care decision is made by some combination of the individual involved, medical staff, and the health care administrators who provide and pay for the decision as it becomes action...

...This control began to wane somewhat after World War n, with the rise of third-party insurers such as Blue Cross/Blue Shield...

...Health can and should mean the maintenance of well-being as well as the defeat of sickness, assisting all lives to wholeness...

...What does this mean, practically...

...In our society, this very specific activity takes place mainly in hospitals...

...Rather, the qualities prized, paid for, and promoted have been "aggressive" institutional aggrandizement, manipulating the financial and bureaucratic system so that the institution gains even if there is a conflict with the health of the populace...

...Presently physicians receive only 20 percent of all health care dollars...

...It also restores thought, reason, and compassion as values in hospital decision-making, as opposed to responses based on custom, inclination, or fear of lawsuit...

...The administrator can easily be several steps removed from actual people with real needs and real suffering...

...These sets of circumstances come from decisions made by administrators and bureaucrats within the health care system...

...3) it is not understood by administrators themselves whose training and inclination often make them view themselves in a subordinate role...

...In the end, it will probably be necessary to have boards and guidelines operating under some broader laws of the society, if only to avoid endless lawsuits...

...Without such a basis of understanding, health care administrators cannot act fully, much less ethically...

...b) resuscitation or destruction of live fetuses...

...These patients had been seen, if at all, by physicians and hospitals who accepted them as "bad debts" and as "teaching material...

...Clinicians have an edge here — they cannot easily escape reality except by the fiercest denial...

...Those decisions must be looked at even more carefully, aware that this is the comparison being made, such as in closing a hospital to further admissions in order to better care for those patients already within the walls...

...The latter are involved on an individual, one-to-one basis...

...This hospital performed abortions up until the end of the second trimester, or twenty-four weeks...

...The currently proposed changes in health-funding by the present administration and those already in place will make the ethical dilemma for administrators that much more acute...

...The professional organizations saw to it that licensed physicians (licensing itself is a control device) were the only legitimated sources of healing...

...The baby was initially diagnosed for an esophageal fistula, for which immediate surgery was planned...

...But the best health care can be gained only when the larger society attends to the issues of distributive justice and compassion implicit in all of these questions...

...It is necessary to provide some basis in law to allow patients who wish to die, or whose families give consent to their death, to be allowed to do so...

...The education and creation of health care administrators who speak from an understanding of the ethical responsibilities of their power will substantially move us toward this goal...

...But after that, each hospital must come to grips with its response to those questions, and here the administrator as manager, leader, and policy-maker must play a key role in ethical decision-making...

...For example, well-appointed group practices can be located in desirable neighborhoods...

...Health insurance had existed before, but after the war, with the widespread inclusion of such insurance into labor union contracts and managerial benefit plans, it became a major force in American health...