Hospital, Contemporary Ethical Problems of the

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HOSPITAL, CONTEMPORARY ETHICAL PROBLEMS OF THE

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Hospitals are complicated institutions that bring together technological innovations and social services, salaried and unsalaried personnel, private and public funding, a charitable mission and a business orientation. Hospitals are accountable to patients, physicians, board members, employees, the local community, third-party payers, business partners, and other providers. It is no wonder that hospitals encounter ethical issues and problems.

Ethical concerns confronting hospitals in the United States are discussed in the following categories: identity and mission; special sponsorship; clinical issues; and relationships with healthcare professionals.

Identity and Mission

Perhaps the most fundamental ethical issue has to do with identity and mission. Is a hospital a business like any other, subject to the pressures of the marketplace, and primarily motivated by commercial interests and incentives? Or is it a social institution, primarily responsible for serving the health needs of the community and sometimes suffering financial loss in the process? These questions fall within the purview of the relatively recently established field of organizational ethics in healthcare. Two edited volumes (by Boyle, DuBose, Ellingson, et al.; and Spencer, Mills, Rorty, et al.) elaborate on these questions and show how hospitals experience tensions between their role as community servants and their role as entrepreneurs. These roles can coexist, as for-profit hospitals have tried to show. However, the public has come to expect more from the nonprofits—for example, that they provide care that is not reimbursed, support unprofitable services, and be alert to community healthcare needs.

Hospitals in the United States face more difficult questions of identity and mission than do hospitals in countries where healthcare is typically regarded as an essential service, not subject to the usual marketplace forces. A confluence of factors—including the growth of scientific medicine, the alliance of physicians and hospitals, the phenomenon of specialization, enormous capital investments, commercial ventures, and the payment system—has caused U.S. hospitals to behave much like businesses. Public policy has encouraged this by endorsing antitrust laws that discourage hospitals' collaboration with one another; by inadequate government-reimbursement programs; and by the failure to ensure universal entitlement to healthcare. These factors create financial incentives for hospitals that conflict with their stated mission, namely, to serve all people and to meet the needs of their communities.

Most hospitals remain not-for-profit and therefore taxexempt. Voluntary hospitals, whose boards of trustees receive no pay because they are understood to serve the community, believe that this community orientation is the most effective way to deliver care. In their rhetoric, they cultivate an image of benevolence and moral worth that obscures their business orientation, seeking government subsidies but eschewing government control. Some business practices adopted by both for-profit and not-for-profit hospitals have tarnished this image of benevolence. These practices include aggressive marketing, advertising, and competition for paying patients; the creation of for-profit ventures, often with physicians, thus creating the potential for conflict of interest; resistance or refusal to care for the indigent; and expensive duplication of services to compete with other hospitals.

Until the latter part of the twentieth century, hospitals could count on the public's trust and support. The special nature of healthcare and the religious affiliation of many hospitals fostered this trust. Contemporary hospitals, however, face increasing skepticism and criticism from patients and the public at large. This dissatisfaction with hospitals' behavior arises from an expectation that hospitals will behave differently from ordinary businesses, that they have a "higher purpose." Distrust also stems from the Institute of Medicine's 2000 report, To Err is Human, which documents high rates of medical errors or unanticipated outcomes occurring in hospitals. It is imperative for hospitals to establish policies toward disclosure of such outcomes, since disclosure facilitates patient trust and reduces legal liability. Yet some hospitals are regaining public trust by various innovations that aim to empower patients to participate in their care (Nolon, Dickinson, and Bolton). Thus, one of the most pressing ethical issues facing hospitals is whether to rededicate themselves to a mission based on altruism and community service. The decision may be compounded by new hospital networks, mergers, and acquisitions. Hospitals still have fundamental ethical choices about whom they serve, how they allocate their resources, and what sort of leadership and vision they bring to providing quality healthcare.

Special Sponsorship

Hospitals under religious sponsorship—Catholic, Jewish, Episcopal, Lutheran, Adventist, Presbyterian, Methodist—have special concerns. They were founded by traditions having particular beliefs and aspirations, yet they provide care in a pluralistic society. They neither employ nor provide care solely for persons of the faith of their founders. Like other hospitals, they are heavily dependent on state and federal payment for services rendered. In some cases, a hospital under religious sponsorship may be the only hospital serving a particular community. Ethical conflicts may arise between hospitals' allegiance to their religious sponsors and their obligation to provide needed services to the community.

This is especially the case in rural settings where, with government funding cuts, hospital closures or consolidations are increasingly common and Catholic health systems acquire nondenominational hospitals in the process. When Catholic hospitals become the primary source of healthcare in a region, rural residents, especially lower-income women, may find it difficult to obtain reproductive health services (Bennett; Bellandi).

Identity and mission are of particular concern here. In the United States, the majority of hospitals are private, that is, they are free to follow their own moral mission in religious matters. A hospital may therefore choose, on religious grounds, to offer different services from others in the community; for example, to follow certain dietary practices, or not to perform blood transfusions, abortions, or sterilizations. Hospitals are also heavily affected by the liability insurance crisis which has lead to the elimination of medical services, such as trauma, and to considerations of tort reform (Haugh; Taylor).

Thus far, the policies of hospitals with religious affiliations have not been proscribed by law, and arguably should not be proscribed ethically, unless they create undue hardship for patients. This would occur if patients could not gain reasonable access to needed services in any other way. The definition of what is reasonable will be interpreted variously, of course, depending on whether the perspective adopted is that of the sponsor and its adherents or of those who desire the service. Sponsored hospitals occasionally find themselves with conflicting loyalties, as they strive to be faithful to both their religious tradition and their constituents.

The growth of managed care and alliances among hospitals of different sponsorships creates another set of ethical conflicts for religious hospitals. If they are part of the new system of healthcare delivery, they will be closely associated with those who practice differently from them. This will result in their cooperating with and financially profiting from the very practices they prohibit in their own hospitals. How hospitals work this out requires careful consideration of their various ethical commitments.

Clinical Issues

With advances in medical technology, hospitals have encountered a number of new and perplexing ethical questions, some of the most contentious arising in relation to the use of life-sustaining treatment. When is it appropriate to withhold or withdraw medical treatment from a critically ill patient? Who should make the decision if the patient cannot? What are the rights and obligations of nurses, physicians, family members? What role should the hospital play in disputes among these groups? What policies should the hospital have in place to deal with these questions?

In 1991, the Joint Commission on Accreditation of Healthcare Organizations (findings published 1992) mandated that hospitals have a process for addressing ethical issues in patient care to protect patients' rights. To satisfy this policy, most hospitals created interdisciplinary ethics committees and used ethics consultants to aid physicians, hospital staff, and patients and their families in mediating individual cases as well as to recommend new policies on forgoing treatment that recognized the preeminence of patient choices. Resuscitation, ventilation, tube and intravenous feeding, renal dialysis, and antibiotic therapy continue to be some of the treatments discussed. Regardless of treatment, patients became entitled to full disclosure about the risks, benefits, and alternatives of treatment; and they, or surrogates, now have the ethical and legal right to accept or refuse any treatment. Many, but not all, physicians and hospitals changed their policies and developed new practices to reflect this situation.

The principle of patient autonomy caused additional ethical dilemmas for hospitals. In the early 1990s, some well-publicized cases arose in which patients' surrogates wanted life-sustaining interventions, but physicians and hospitals did not want to provide them. A claim of medical futility was the usual reason for this reluctance, although disputes about whether research had shown the desired treatment, such as cardiopulmonary resuscitation (CPR), to be reasonably effective also arose. Patients and surrogates invoked the principle of autonomy to justify their demands for treatment. These demands were particularly strong if the patient, or the patient's insurer, was willing to pay for the treatment.

Physicians and hospitals thus faced new issues: What are the limits of patients' or surrogates' rights to medical treatment? Are there situations in which physicians are justified in refusing to provide it? Is it ethical for physicians to have in mind scarce hospital resources when treating individual patients? What is the meaning, and what are the ethical implications, of medical futility? What are the economic and/or ethical conflicts of interest for hospitals in these cases?

These questions are inextricably related to the nature of insurance coverage. If insurance companies pay on a per diem or fee-for-service basis, it is to the hospital's advantage that patients have extensive treatment and long hospital stays, particularly if the insurance pays close to the actual cost of caring for the patient. In the late 1980s, many insurers changed the method of payment to capitation. Under this method, hospitals are at risk and receive a predetermined reimbursement for each patient, regardless of the actual costs of caring for the patient. Capitation creates very different economic incentives for physicians and hospitals than they have under a fee-for-service system. Thus, money becomes a factor in responding to the ethical question of who should decide when treatment should be provided. If the public thinks it is not receiving the medical care it needs because hospitals and/or physicians fear losing money, trust between healthcare providers and those they serve will be further eroded. Hospitals must therefore demonstrate their commitment to community service and educate the public about the importance of cost control. In order for trust to be renewed, the public must understand the connection between limiting expensive treatments for some patients and providing more basic care for others. They will need to agree that such changes are not primarily for the economic benefit of healthcare providers but are for the benefit of society as a whole.

Public trust in hospitals and clinical care is also waning due to greater awareness or experiences of sociodemographic disparities in healthcare (Smedley, Stith, and Nelson). The U.S. Department of Health and Human Services has established as a top priority the elimination of health disparities across racial/ethnic groups, sex, age, and geographic location. Hospitals have the capacity to contribute substantially toward this aim by ensuring the availability of qualified interpreters, employing healthcare professionals of diverse ethnic backgrounds, and providing culturally competent care. When justice can be secured through the provision of healthcare to individuals regardless of their cultural or religious backgrounds, the quality of healthcare will improve (Smedley, et al.; Committee on Quality of Health Care in America).

Relationships with Healthcare Professionals

Hospitals and physicians have always had an uneasy alliance: They need each other but often do not trust each other. For the first half of the twentieth century, hospitals were referred to as the "physicians' workshop." Hospitals provided the beds, equipment, nurses, and other personnel, and physicians provided the patients. Except in teaching institutions, hospitals and physicians had few common goals and mutual responsibilities beyond providing a place to care for patients. Physicians directed all aspects of patient care, and expected hospitals and their personnel to provide whatever the physicians deemed necessary. Until the middle of the twentieth century, hospitals themselves were not legally responsible for the care provided by physicians. At that time, courts began finding hospitals and their employees liable for not intervening to protect the patient when physicians provided inferior care. Since that time, hospitals have instituted mechanisms to monitor and intervene when necessary in physicians' care of patients.

This change was good for patients, but strained the relationship between hospitals and physicians. It created ethical conflicts for hospitals when, for example, physicians who admitted large numbers of patients were questioned or disciplined regarding quality of care. Some of these physicians left the hospitals, taking a large source of revenue with them. Accountability to patients required that hospitals and their organized medical staffs be vigilant about monitoring and intervening in the quality of care practiced by physicians. Economic self-interest, however, tempted hospitals to be more lenient with physicians.

Toward the end of the twentieth century, relationships between hospitals and physicians began to change again. Integrated delivery systems, through which healthcare providers and payers (such as insurance companies) collaborate to deliver care to patients in a particular geographic region, align the economic incentives affecting both physicians and hospitals. Capitation, a fixed fee paid to a group of providers to provide care for a fixed number of patients, resolves some of the ethical problems of the past related to hospital reimbursement. But capitation creates new ethical issues due to economic incentives to provide the least expensive care to patients. This change is good for some patients, but may not be good for others. Hospitals will continue to face ethical dilemmas of conflicting loyalties to patients and physicians.

The introduction of integrated delivery systems changes the relationships between hospitals and physicians in other ways. Some managed care plans require that primary-care physicians be the "gatekeepers," seeing patients first and referring them to specialists only if absolutely necessary. This, combined with capitation systems, creates incentives for hospitals and primary-care physicians to offer their services as one unit. However, the retreat of managed care has signaled increased access to healthcare providers while increasing healthcare costs (Robinson, 2001). Many hospitals that purchase physicians' medical practices manage the business side of the practices. This is extremely difficult to accomplish with ethical integrity on both sides, because physicians and hospitals have historically operated independently of one another—both psychologically and practically—even though they are in the same building.

A related problem is that, after having courted specialists for years, hospitals now rely on primary-care physicians to direct patients to specialists. Nevertheless, ethical issues of loyalty and integrity are raised, as physicians in specialty practices find themselves in professional and economic jeopardy when their interests no longer match those of their hospital.

In response to the restrictions healthcare organizations impose upon physicians to control costs and medical decisionmaking, the American Medical Association established a union, Physicians for Responsible Negotiations, in 1999. Subsequently, medical residents separately unionized in 1999, limiting the number of work hours required per week. These unionizations can have a profound impact on hospitals (Yacht; Cohen). Some hospitals and physicians are concerned that unionization will lead to strikes, interfere with education and patient care, and add to hospital finances, as well as undermine the meaning of medical professionalism. Accounts of unionization at some hospitals, however, reveal that such fears do not materialize, given that these labor organizations have banned strikes to prioritize patient care (Yacht).

Hospitals face other problems with the delivery of medical care in relation to physicians and managed care. Managed care plans are increasingly utilizing evidence-based medicine guidelines to enhance efficiency in medical care by eliminating overtreatment and undertreatment (Sackett, Straus, Richardson, et al.). Many physicians fear that such guidelines interfere with personalized patient care, which deters their willingness to implement them. Consequently, hospitals may not be able to reach levels of clinical practice to which they aspire.

Much attention has also turned to the relationship between hospitals and nurses, given the critical shortage of nurses. This shortage results from efforts to contain hospital costs, and it contributes to medical errors and poor patient care. Although technicians and nursing aids have been hired to perform some nursing duties, it remains to be determined how hospitals will recruit a sufficient number to provide appropriate nursing care.

Conclusion

Contemporary hospitals encounter many ethical concerns and problems. All constituents—patients, physicians, employees, board members, volunteers, the community at large, payers, business partners—have a stake in the way these ethical issues are considered and resolved.

corrine bayley (1995)

revised by elisa j. gordon

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Encyclopedia of Bioethics