Who determines the value of medical outcomes?
Allocating resources is a global concern
Before the age of managed care, the vast majority of medical interventions became accepted practice because they worked for some patients. But with health care costs rising and accountability for the use of every dollar becoming a norm, some medical ethics professionals are alarmed that the "value" of certain treatments is being decided by those with cost, not care, on their minds.
Ethicists also worry that before patients and health care ethics committee members realize it has happened, the values in today’s health care delivery system will be firmly entrenched based on medical outcomes, a mainstay of managed care.
Ethics committees should lead the way
"Various individuals have a stake in medical outcome data," says John Banja, PhD, associate professor of rehabilitation medicine at Emory University in Atlanta. "There is value in the patient outcome as it pertains to the patient, the scientist, and the insurer," he says.
The key questions are where does the value of an outcome actually come from, and are opposing views being considered, argues Susan B. Rubin, PhD, associate professor at San Francisco State University and co-founder of The Ethics Practice in Berkeley, CA.
For example, does your hospital or institution contract with a managed care company that determines coverage for a certain procedure and not others, for certain patients and not others? As managed care becomes rooted in our health care delivery system, ethics committees need to lead the way on developing guidelines in this area.
"Ethics committees have traditionally left these allocation decisions to the physician," Banja says. "It seems to me that these should be largely organizational decisions that are guided by ethical principles."
Involve the community
Speaking recently before the American Medical Association about who should control the scope of medical ethics, Mark Seigler, MD, director of the MacLean Center for Clinical Medical Ethics at the University of Chicago, suggested that clinical ethics should be much more than case discussion, consultation, or "applied medical causistry." Its goal, he said, "would be to improve clinical care and medical outcomes."
Seigler urged ethics committees to do less talking and thinking and take more action to improve routine practices in their own health care settings. Banja and Rubin urge institutional ethics committee members to identify allocation problems in their facilities. "I see this as a natural extension of the ethics committee’s role," Rubin says.
Ethics committees should stimulate discussions of what is valuable in a delivery system, in a managed care agreement, and in practice guidelines for physicians, nurses, or other caregivers. Take the discussion to the public. Help stim- ulate community debate over health care values, Rubin says.
No better example exists of defining values based on outcomes than the current debate over medical futility. Treatments such as cardiopulmonary resuscitation are futile, Rubin explains, only when they fail to meet a particular goal.
"Reframing futility discussions in the language of goals is one of the most effective ways of uncovering and addressing the moral appeals at stake in conflicts among patients and their care providers," she says.1
"How do we decide the value of CPR? Will it [the criterion] be discharge to the home or a return to restored function for a short time before ultimate death?" Rubin asks.
Start looking at your own risks’
Both Rubin and Banja are plagued by the notion that something as sacrosanct as resuscitation may be rationed based on outcomes rather than on the value extended life has for patients and their loved ones.
"There are many, many examples of allocation of care in all health care facilities," Banja says. "For a provider that wants to achieve a high moral ground, start looking at your own risks in this regard."
Identify general and specific allocation examples. Keep data. Make decisions and develop policies and practice guidelines based on predetermined organizational values, he says.
Focusing the debate
Ultimately, ethics committees should set an example of how to place ethical values, not financial ones, at the core of the debate. Ethics committees must help create discussions about how to evaluate new outcomes data justly, how to allow for cultural differences in the selection of goals, and how to facilitate end-of-life decision making.1
Ethics committees also might want to do some soul-searching about the values and outcomes of their work, Siegler adds.
Reference
1. Zoloth-Dorfman L, Rubin S. Medical futility: Managed care and the powerful new vocabulary for clinical and public policy discourse. Healthcare Forum J 1997; March/April:28-33.
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