From a giant of health care policy, an engaging and enlightening account of why American health care is so expensive -- and why it doesn't have to be. Uwe Reinhardt was a towering figure and moral conscience of health care policy in the United States and beyond. Famously bipartisan, he advised presidents and Congress on health reform and originated central features of the Affordable Care Act. In Priced Out, Reinhardt offers an engaging and enlightening account of today's U.S. health care (...) system, explaining why it costs so much more and delivers so much less than the systems of every other advanced country, why this situation is morally indefensible, and how we might improve it. The problem, Reinhardt says, is not one of economics but of social ethics. There is no American political consensus on a fundamental question other countries settled long ago: to what extent should we be our brothers' and sisters' keepers when it comes to health care? Drawing on the best evidence, he guides readers through the chaotic, secretive, and inefficient way America finances health care, and he offers a penetrating ethical analysis of recent reform proposals. At this point, he argues, the United States appears to have three stark choices: the government can make the rich help pay for the health care of the poor, ration care by income, or control costs. Reinhardt proposes an alternative path: that by age 26 all Americans must choose either to join an insurance arrangement with community-rated premiums, or take a chance on being uninsured or relying on a health insurance market that charges premiums based on health status. An incisive look at the American health care system, Priced Out dispels the confusion, ignorance, myths, and misinformation that hinder effective reform. (shrink)

Many transgender people need specific medical services to affirm their gender. Gender-affirming health care services may include mental health support, hormone therapy, and reconstructive surgeries. Scant information is available about the utilization or costs of these services among transgender people, which hinders the ability of insurance regulators, health plans, and other health care organizations to plan and budget for the health care needs of this population and to ensure that transgender people can access medically necessary gender-affirming care. This study (...) used almost three decades of commercial insurance claims from a proprietary database containing data on more than 200 million people to identify temporal trends in the provision of gender-affirming hormone therapy and surgeries and to quantify the costs of these services. (shrink)

The new Hungarian Labour Code allows informal payments to be accepted, subject only to the prior permission of the employer. In Hungary, the area most affected is Health Care, where informal payments to medical staff are common. The article assesses the practice on ethical terms, focusing on organisational justice. It includes an analysis of distributional injustice, that is, of non-equitable payments to professionals, on the distribution of payments depending on the specialisation and status of the doctor, on his or (...) her rights to allocate Health Care resources and/or on how assertive he or she is. We show, by means of a content analysis of internet postings and of interviews with physicians, the feelings and attitudes of both patients and doctors—thus enabling us to trace interactional and procedural injustice and portray the main driving forces of informal payment with causal loops. We use a new approach (a system dynamics computer simulation) to demonstrate how informal payments influence therapy procedures. The example of treating the common skin disease of psoriasis examines the specific behaviour of doctors in their everyday practice and estimates the extent to which the prescription of unnecessary or more expensive therapy increases the costs. With this multi-method approach, we demonstrate that the legislation allowing informal payment represents bad ethics, since it enforces organisational injustice, creates mistrust between physicians and patients, decreases performance and increases the total costs paid both by society and the Health Insurance Fund. Informal payments distort the allocation of resources, enforce discrimination based solely on money, violate the concept of solidarity and limit Human Rights in terms of health. (shrink)

Medicine and Money explores the role of beneficence and cost control in health-care systems. The book's primary concern of morally improving medicine is achieved by dividing the argument into two parts. The first defines the crisis in health-care and justifies beneficence. The second part offers practical suggestions on implementing beneficence into the system. Medicine and Money is one of the few books to provide concrete suggestions on improving the health-care system from the micro level for addressing cost concerns (...) in a morally acceptable manner. (shrink)

BackgroundIn the 1970s, the Federal Trade Commission declared that allowing medical providers to advertise directly to consumers would be “providing the public with truthful information about the price, quality or other aspects of their service.” However, our understanding of the advertising content is highly limited.ObjectiveTo assess whether direct-to-consumer medical service advertisements provide relevant information on access, quality and cost of care, a content analysis was conducted.MethodTelevision and online advertisements for medical services directly targeting consumers were collected (...) in two major urban centres in Nevada, USA, identifying 313 television advertisements and 200 non-duplicate online advertisements.ResultsBoth television and online advertisements reliably conveyed information about the services provided and how to make an appointment. At the same time, less than half of the advertisements featured insurance information and hours of operation and less than a quarter of them contained information regarding the quality and price of care. The claims of quality were substantiated in even fewer advertisements. The scarcity of quality and cost information was more severe in television advertisements.ConclusionThere is little evidence that medical service advertising, in its current form, would contribute to lower prices or improved quality of care by providing valuable information to consumers. (shrink)

Crowdfunding websites allow users to post a public appeal for funding for a range of activities, including adoption, travel, research, participation in sports, and many others. One common form of crowdfunding is for expenses related to medical care. Medical crowdfunding appeals serve as a means of addressing gaps in medical and employment insurance, both in countries without universal health insurance, like the United States, and countries with universal coverage limited to essential medical needs, like Canada. For (...) example, as of 2012, the website Gofundme had been used to raise a total of 8.8 million dollars for seventy-six hundred campaigns, the majority of which were health related. This money can make an important difference in the lives of crowdfunding users, as the costs of unexpected or uninsured medical needs can be staggering. In this article, I offer an overview of the benefits of medical crowdfunding websites and the ethical concerns they raise. I argue that medical crowdfunding is a symptom and cause of, rather than a solution to, health system injustices and that policy-makers should work to address the injustices motivating the use of crowdfunding sites for essential medical services. Despite the sites’ ethical problems, individual users and donors need not refrain from using them, but they bear a political responsibility to address the inequities encouraged by these sites. I conclude by suggesting some responses to these concerns and future directions for research. (shrink)

The Oregon Basic Health Services Act of 1989 seeks to establish universal access to basic medical care for all currently uninsured Oregon residents. To control the increasing cost of medical care, the Oregon plan will restrict funding according to a priority list of medical interventions. The basic level of medical care provided to residents with incomes below the federal poverty line will vary according to the funds made available by the Oregon legislature. A rationing plan (...) such as Oregon's which potentially excludes medically necessary procedures from the basic level of health care may be just, for the right to publically-sponsored medical care is restricted by opposing rights of private property. However, the moral acceptability of the Oregon plan cannot be determined in the absence of knowing the level of resources to be provided. Finally, Oregon to date has failed to include the individuals being rationed in discussions as to how the scarce resources are to be distributed. (shrink)

This report is about ethical thinking in the field of health and health care. But it is no abstract philosophical tract. It is designed to be of practical help to those struggling with the complex questions of allocating resources in health care and to encourage a wider involvement at all levels in health debates. The questions it raises stimulate new thinking about today's institutional structures. As we proceeded with our work, we became aware that it is easier to state problems (...) than to solve them. However, we were also aware of the opposite danger of oversimplification implicit in the view that there was a moral calculus to which decisionmakers could turn when they were confronted by an ethical problem in the allocation of resources, and which would yield mechanical solutions to human problems. (shrink)

The purpose of this paper is to review the rising influence of commercialism in American medicine and to examine some of the consequences of this trend. Increased competition subverts physician collegiality, draws hospitals into for-profit ownership and behavior, and leads clinical investigators into secrecy and possibly into bias and abuse. Medicine faces a deprofessionalization evidenced in loss of control over the clinical setting and over self-regulation. Health care becomes a commodity relying on cultivation of desires instead of satisfaction of needs, (...) even as many basic needs go unmet. Patients become consumers empowered with lawsuits and the connection of medicine to the relief of suffering is attenuated. Medical encounters are increasingly impersonal, dominated by specialization, technology, and bureaucracy. Patients are losing their physician-advocates to new conflicts of interests, physicians are losing their impulse to charity, and trust in the doctor-patient relationship and in medicine generally is eroding. (shrink)

Rehabilitation for disabled children requires long-term programmeswhich are expensive to the family. This study aimed to estimate the costincurred by caregivers’ children with disabilities from Pahang, Terengganu andKelantan participating in Community-Based Rehabilitation and cost of seeking alternative rehabilitation. Costanalysis using the Activity-Based Costing method was used to estimatetwelve-months’ expenditure in 2014 institutional year on 297 caregivers ofchildren with disability, aged 0 to 18 years who attended CBR. Data werecollected using a self-administered costing questionnaire and presentedin median. Results showed that (...) the median direct and indirect costs,excluding medications and alternative care were nearly four times as highin Home-Based compared to Centre-Based vs. RM608. Both groups of caregivers spent a significant amount ofresources on alternative rehabilitation. The high costs incurred for alternativerehabilitation is a major economic burden to the family. (shrink)

Patients and family members (N = 671) were surveyed in five Mid-Atlantic U.S. hospitals to ascertain the number and kinds of ethical concerns they are presently experiencing or have previously experienced while being sick or receiving medical care. Seventy percent of participants had at least one (range 0–14) type of ethical concern or question. The most commonly experienced concerns pertained to being unsure how to plan ahead or complete an advance directive (29.4%), being unsure whether someone in the family (...) was able to make their own decisions (29.2%), deciding about limiting life-sustaining treatments (28.6%), wondering about disclosing personal medical information to others in the family (26.4%) and not being sure whether to undergo treatment because of cost (26.2%). Most were interested to some degree in getting help from ethics consultants in the future (76.6%). Given this prevalence, common concerns might usefully be addressed systematically, rather than exclusively on a case-by-case basis. (shrink)

Background: The health professionals are involved in the paths of care for patients with different medical conditions. Their life is frequently characterized by psychopathological outcomes so that it is possible to identify consistent burdens. Besides the possibility to develop pathological outcomes, some protective factors such as resilience play a fundamental role in facilitating the adaptation process and the management of maladaptive patterns. Personal characteristics and specific indexes such as burdens and resilience are essential variables useful to study in-depth ongoing (...) conditions and possible interventions. The study was aimed at highlighting the presence and the relations among factors as personal variables, burdens, and resilience, to understand health professionals' specific structure and functions.Methods: The observation group was composed of 210 participants, 55 males, and 155 females, aged from 18 to 30 years old with a mean age of 25.92 years old. The study considered personal characteristics of the subjects, such as age, gender, years of study, days of work per week, hours of work per week, and years of work. Our study had been conducted with the use of measures related to burdens and resilience.Results: The performed analyses consisted of descriptive statistics, correlations, and regressions among the considered variables. Several significant correlations emerged among personal characteristics, CBI, and RSA variables. Specifically, age and work commitment indexes appeared to be significantly related to the development of burdens, differently from the years of study. Significant correlations emerged among personal and RSA variables, indicating precise directions for both domains. Age and gender were identified as predictors to perform multivariate regression analyses concerning CBI factors. Significant dependence relations emerged with reference to all CBI variables.Conclusion: Pathological outcomes and resilience factors represent two sides of the health professionals' experiences, also known as “invisible patients.” Greater knowledge about present conditions and future possibilities is a well-known need in literature so that the current analyses considered fundamental factors. In line with state of the art, future studies are needed in order to deepen elusive phenomena underlying maladjustment. (shrink)

Patients have a right to refuse medical treatment. But what should happen after a patient has refused recommended treatment? In many cases, patients receive alternative forms of treatment. These forms of care may be less cost-effective. Does respect for autonomy extend to providing these alternatives? How for does justice constrain autonomy? I begin by providing three arguments that such alternatives should not be offered to those who refuse treatment. I argue that the best argument which refusers can appeal (...) to is based on the egalitarian principle of equality of outcome. However, this principle does not ultimately support a right to less cost-effective alternatives. I focus on Jehovah's Witnesses refusing blood and requesting alternative treatments. However, the point applies to many patients who refuse cost-effective medical care. (shrink)

The question of how to allocate scarce medical resources has become an important public policy issue in recent decades. Cost-Utility Analysis is the most commonly used method for determining the allocation of these resources, but this book counters the argument that overcoming its inherent imbalances is simply a question of implementing methodological changes. The Economics of Resource-Allocation in Healthcare represents the first comprehensive analysis of equity weighting in health care resource allocation that offers a fundamental critique of its (...) basic framework. It offers a heterodox account of health economics, putting the discourse on economic evaluation into it broader socio-political context. Such an approach broadens the debate on fairness in health economics and ties it in with deeper rooted problems in moral philosophy. Ultimately, this interdisciplinary study calls for the adoption of a fundamentally different paradigm to address the distribution of scarce medical resources. This book will be of interest to policy makers, health care professionals or Post-Graduate students looking to broaden their understanding of the economics of the healthcare system. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision (...) makers distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

As costs decline and technology inevitably improves, current trends suggest that artificial intelligence (AI) and a variety of "carebots" will increasingly be adopted in medical care. Medical ethicists have long expressed concerns that such technologies remove the human element from medicine, resulting in dehumanization and depersonalized care. However, we argue that where shame presents a barrier to medical care, it is sometimes ethically permissible and even desirable to deploy AI/carebots because (i) dehumanization in medicine is not always (...) morally wrong, and (ii) dehumanization can sometimes better promote and protect important medical values. Shame is often a consequence of the human-to-human element of medical care and can prevent patients from seeking treatment and from disclosing important information to their healthcare provider. Conditions and treatments that are shame-inducing offer opportunities for introducing AI/carebots in a manner that removes the human element of medicine but does so ethically. We outline numerous examples of shame-inducing interactions and how they are overcome by implementing existing and expected developments of AI/carebot technology that remove the human element from care. (shrink)

It probably should not be surprising, in this time of soaring medical costs and proliferating technology, that an intense debate has arisen over the concept of medical futility. Should doctors be doing all the things they are doing? In particular, should they be attempting treatments that have little likelihood of achieving the goals of medicine? What are the goals of medicine? Can we agree when medical treatment fails to achieve such goals? What should the physician do and (...) not do under such circumstances? Exploring these issues has forced us to revisit the doctor-patient relationship and the relationship of the medical profession to society in a most fundamental way. Medical futility has both a quantitative and qualitative component. I maintain that medical futility is the unacceptable likelihood of achieving an effect that the patient has the capacity to appreciate as a benefit. Both emphasized terms are important. A patient is neither a collection of organs nor merely an individual with desires. Rather, a patient (from the word to suffer ) is a person who seeks the healing (meaning to make whole ) powers of the physician. The relationship between the two is central to the healing process and the goals of medicine. Medicine today has the capacity to achieve a multitude of effects, raising and lowering blood pressure, speeding, slowing, and even removing and replacing the heart, to name but a minuscule few. But none of these effects is a benefit unless the patient has at the very least the capacity to appreciate it. Sadly, in the futility debate wherein some critics have failed or refused to define medical futility an important area of medicine has in large part been neglected, not only in treatment decisions at the bedside, but in public discussions—comfort care—the physician’s obligation to alleviate suffering, enhance well being and support the dignity of the patient in the last few days of life. (shrink)

Rising health insurance costs and the cost of living crisis are likely leading to an increase in unpaid health insurance bills in many countries. In Switzerland, a particularly drastic measure to sanction defaulting insurance payers is employed. Since 2012, Swiss cantons – who have to cover most of the bills of defaulting payers - are allowed by federal law to blacklist them and to restrict their access to medical care to emergencies.In our paper, we briefly describe blacklisting in (...) the context of the Swiss healthcare system before we examine the ethical issues involved in light of what is known about its social and health impacts. We found no evidence that blacklisting serves as an effective way of recovering unpaid health insurance contributions or of strengthening solidarity within the health insurance system. Furthermore, the ambiguous definitions of what constitutes an emergency treatment and the incompatibility of the denial of medical care with the obligation to provide professional assistance complicate the implementation of blacklists and expose care providers to enormous pressure.Therefore, we conclude that blacklists and the (partial) denial of medical care not only pose profound ethical problems but are also unsuitable for fulfilling the purpose for which they were introduced. (shrink)

This book is a comprehensive account of what it means to try to quantify health in distributing resources for health care. It examines the concept of QALYs which supposedly makes it more accurate to talk about life in terms of both quality and quantity of years lived when referring to health care policy. It offers an elegant new approach to comparing the costs and benefits of medical interventions. Cost-Utility Analysis is a method designed by economists to aid decision (...) makers distribute scarce resources to areas of health care where they will yield the greatest benefits. Erik Nord questions the feasibility of measuring patients' quality of life meaningfully in numerical terms, as CUA presupposes. He presents an alternative approach called cost-value analysis in which representative samples of the general public express preferences between different health-care programs. In this approach, subjects are allowed to include concerns for fairness that go beyond concerns for efficiency of conventional health economics. (shrink)

The drive for cost-effective use of medical interventions has advantages, but can also be challenging in the context of end-of-life palliative treatments. A quality-adjusted life-year (QALY) provides a common currency to assess the extent of the benefits gained from a variety of interventions in terms of health-related quality of life and survival for the patient. However, since it is in the nature of end-of-life palliative care that the benefits it brings to its patients are of short duration, it (...) fares poorly under a policy of QALY-maximization. Nevertheless, we argue that the goals of palliative care and QALY are not incompatible, and optimal integration of palliative care into the calculation of QALY may reveal a mechanism to modify considerations of how optimal quality of life can be achieved, even in the face of terminal illness. The use of QALYs in resource allocation means that palliative care will always compete with alternative uses of the same money. More research should be conducted to evaluate choices between palliative care and more aggressive therapies for the terminally ill. However, current limited data show that investing in palliative care makes more sense not only ethically, but also financially. (shrink)

Julian Le Grand's case for saying that it would be equitable if smokers and smokers alone were to pay the costs of smoking-related health care is considered and found to be deficient.

For-profit managed care organizations face decisions about cost sharing that can involve a tradeoff between the interests of investors and the interests of patients. No successful business can ignore the interests of its investors, but moral philosophy points to ethical reasons for managed care organizations to make patients’ health, rather than investors’ profit, their primary goal. One reason is the ethical obligation of all businesses to avoid wrongful exploitation of vulnerable customers. An insurance company’s cost-sharing policy can exploit (...) customers either by collecting an unfairly large amount of money from them or by unfairly deterring them from making claims for resources they medically need. Another reason stems from the fact that managed care organizations’ profits derive in part from the existence of artificial barriers to access to medicine, notably including patents. Putting a fence around a water well in the desert is legitimate only if doing so facilitates a financial arrangement that maximizes people’s access to water they need. Likewise, patents and other artificial barriers to access to medically necessary drugs are legitimate only if they are used to help finance access to medical resources people need. For these reasons, managed care organizations should make cost-sharing decisions that maximize the sustainable availability of effective drugs to patients who need them. (shrink)

Contemporary cost containment measures ignore patients' need for privacy, destroy long-term doctor-patient relationships, and demand ethical and standard of care compromises.Economic considerations have distracted the physician and he/she no longer focuses primarily on the patient's welfare. The superficiality of the doctor-patient relationship and the cost-cutting efforts have jointly contributed to the deterioration of the quality of medical care.

Book reviewed in this article: Balancing Act: The New Medical Ethics of Medicine's New Economics. By E. Haavi Morreim.

Objectives Medical futility at the end of life is a growing challenge to medicine. The goals of the authors were to elucidate how clinicians define futility, when they perceive life-sustaining treatment (LST) to be futile, how they communicate this situation and why LST is sometimes continued despite being recognised as futile. Methods The authors reviewed ethics case consultation protocols and conducted semi-structured interviews with 18 physicians and 11 nurses from adult intensive and palliative care units at a tertiary hospital (...) in Germany. The transcripts were subjected to qualitative content analysis. Results Futility was identified in the majority of case consultations. Interviewees associated futility with the failure to achieve goals of care that offer a benefit to the patient's quality of life and are proportionate to the risks, harms and costs. Prototypic examples mentioned are situations of irreversible dependence on LST, advanced metastatic malignancies and extensive brain injury. Participants agreed that futility should be assessed by physicians after consultation with the care team. Intensivists favoured an indirect and stepwise disclosure of the prognosis. Palliative care clinicians focused on a candid and empathetic information strategy. The reasons for continuing futile LST are primarily emotional, such as guilt, grief, fear of legal consequences and concerns about the family's reaction. Other obstacles are organisational routines, insufficient legal and palliative knowledge and treatment requests by patients or families. Conclusion Managing futility could be improved by communication training, knowledge transfer, organisational improvements and emotional and ethical support systems. The authors propose an algorithm for end-of-life decision making focusing on goals of treatment. (shrink)

Providing care for a baby born at 24 weeks of gestation in a neonatal intensive care unit is one of the most expensive medical treatments in the United States today. The cost can easily run over $300,000 for one baby. Furthermore, many extremely premature babies who survive are left with chronic diseases or disabilities that require further medical expenses and other specialized services throughout childhood or throughout life. When all these expenditures are totaled up, it can seem (...) that neonatal intensive care is just not worth it.Concerns about the cost-effectiveness of NICUs have led to persistent critical scrutiny of these specialized units by physicians, economists, and epidemiologists. These analysts have examined NICUs and the patients in them in order to determine whether there are subpopulations of babies for whom neonatal intensive care is so demonstrably ineffective or so costly that it should not be provided. Such examinations have been carried out in many different countries, at many times over the last 30 years, and have analyzed outcomes for babies by gestational age, birthweight, and illness severity. (shrink)

Neonatal intensive care units (NICUs) and medical intensive care units (MICUs) are both very expensive. The cost-effectiveness of NICUs has been extensively evaluated, as has the long-term outcomes of subpopulations of NICU patients. NICU treatment is among the most cost-effective of high-tech interventions. And most patients do well. There are fewer evaluations of cost-effectiveness in the MICU and almost no long-term outcome studies. Policymakers who scrutinize expensive high-tech interventions would do well to study the examples found (...) in the NICU. (shrink)

: Four principal arguments have been offered in support of requiring public and private third-party payers to help fund medical research: (1) many of the costs associated with clinical trial participation are for routine care that would be reimbursed if delivered outside of a trial; (2) there is a need to promote scientific research and medical progress and lack of coverage is an impediment to enrollment; (3) to cover the costs of trials expands health care and treatment options (...) for the sick; and (4) it is beneficial for private insurers to cover the costs associated with cancer clinical trials because doing so makes such companies more attractive to consumers. Although many see third-party-payer coverage as a victory for patients and for the future of research, requiring coverage of services provided in a trial beyond those that would be provided to a comparable patient outside the research context raises a number of concerns. (shrink)

A hypothetical scenario is presented in which a female patient is admitted to a private hospital to undergo a mastectomy and breast reconstruction. The surgeons and anaesthetists conducting the different procedures charge three times the medical aid rates. When the patient asks what the co-payments are likely to be, she is informed by the doctors’ accounts section that they can only provide this information after each procedure. The patient’s medical scheme also advises her that it cannot determine the (...) likely co-payments unless she completes the assessment form sent to her. The form requires her to include the costs reflected against the relevant ICD10 codes. The patient cannot complete the form because the doctors’ accounts sections have not informed her about the proposed procedures and the likely costs of each. This article builds on a previous article discussing doctors’ overarching responsibility to disclose medical treatment costs in advance. The present article outlines the legal requirements in the South African Constitution, the National Health Act and the Health Professions Act, and refers to the Promotion of Access to Information Act and Consumer Protection Act. Similar to the earlier article, this article addresses the ethical requirements of the Health Professions Council of South Africa and the internationally recognised biomedical ethical principles. Furthermore, it also refers to the National Patients Charter, the government’s policy document on health care services. (shrink)

Ethical analyses, professional guidelines and legal decisions support the equivalence thesis for life-sustaining treatment: if it is ethical to withhold treatment, it would be ethical to withdraw the same treatment. In this paper we explore reasons why the majority of medical professionals disagree with the conclusions of ethical analysis. Resource allocation is considered by clinicians to be a legitimate reason to withhold but not to withdraw intensive care treatment. We analyse five arguments in favour of non-equivalence, and find only (...) relatively weak reasons to restrict rationing to withholding treatment. On the contrary, resource allocation provides a strong argument in favour of equivalence: non-equivalence causes preventable death in critically ill patients. We outline two proposals for increasing equivalence in practice: (1) reduction of the mortality threshold for treatment withdrawal, (2) time-limited trials of intensive care. These strategies would help to move practice towards more rational treatment limitation decisions. (shrink)

Providing health care in the most cost-effective way has become a priority in recent years. This book tackles the important issue of the potential conflict between economic expediency and the welfare of individual patients. Contributors examine different attitudes to this complex problem, along with a variety of legal and historical perspectives. The book addresses particular aspects of health care, such as medical expert systems, general practice, medical education, and clinical decision-making where the direct involvement of doctors in (...) allocating scarce and expensive resources is perhaps most obvious. (shrink)

This series of articles by Charles Dougherty, Robert Berenson, and Kathleen Powderly and Elaine Smith, as well as “Cost Containment: Challenging Fidelity and Justice” by E. Haavi Morreim (Hastings Center Report, December 1988), result from a Hastings Center project, “Ethics and Prospective Payment Systems: DRGs.” The two-year project was jointly funded by The General Electric Foundation and the American Medical Association Education and Research Foundation.The project tried to gauge the systematic effects of the introduction of cost containment (...) strategies, prospective payment by Diagnostic Related Groups in particular, on the provision of health care and the ethical practice of medicine. Cost containment strategies, no matter how necessary in curbing spiraling medical costs, leave no sector or participants in the health care system untouched—hospitals and other health care institutions; doctors, nurses, social workers and other health care professionals; patients, their families, and the thirty-six to forty million medically indigent. The articles discuss the several and interrelated ethical issues raised by the DRG prospective payment system (Dougherty); its particular affect on the doctor-patient relationship and how it is transforming the ethical practice of medicine (Berenson and Morreim); and its specific impact on the professions and professional ethics of nursing and social work (Powderly and Smith). The overall message of the articles is that the health professions, their provision of care, and the ethics of their practices—as driven by economic considerations and realities—are in the midst of a more or less radical sea change. (shrink)

There are two discourses that are used in connection with the provision of good healthcare: a rights discourse and a beneficial design discourse. Although the logical force of these two discourses overlaps, they have distinct and incompatible implications for practical reasoning about health policy. The language of rights can be interpreted as the ground of a well-designed healthcare system stressing the values of equality and inclusion, but it has less application when dealing with questions of cost-effectiveness. This difference reflects (...) the distinction between the deontological status of rights claims and a teleological approach presupposed in the language of beneficial design. However, the value of the separateness of persons contained in the discourse of rights can impose constraints on the adoption of a simple maximizing principle when thinking about the allocation of healthcare resources within a social contract for health. Throughout these issues are discussed by reference to the work of Peter Jones. (shrink)

When do you have to sacrifice life and limb, time and money, to prevent harm to others? When must you save more people rather than fewer? These questions might arise in emergencies involving strangers drowning or trapped in burning buildings, but they also arise in our everyday lives, in which we confront opportunities to donate time or money to help distant strangers in need of food, shelter, or medical care. With the resources available, we can provide more help--or less. (...) -/- In The Rules of Rescue, Theron Pummer argues that we are often morally required to engage in effective altruism, directing altruistic efforts in ways that help the most. Even when the personal sacrifice involved makes it morally permissible not to help at all, he contends, it often remains wrong to provide less help rather than more. Using carefully crafted examples, he defends the view that helping distant strangers is more morally akin to rescuing nearby strangers than most of us realize. The ubiquity of opportunities to help distant strangers threatens to make morality extremely demanding, and Pummer argues that it is only thanks to adequate permissions grounded in considerations of cost and autonomy that we may pursue our own plans and projects. He ultimately concludes that many of us are required to provide no less help over our lives than we would have done if we were effective altruists. (shrink)

Physicians and institutional providers face expanding liability exposure today, in spite of state tort reform legislation and public awareness of the costs of malpractice for providers. Standards of practice are evolving rapidly; new medical technologies are being introduced at a rapid rate; information is proliferating as to treatment efficacy, patient risk, and diseases generally. Tort standards mirror this change. As medical standards of care evolve, they provide a benchmark against which to measure provider failure. The liability exposure of (...) physicians is affected by the generation of data, including outcomes data usable to profile physician practice, and statistical data that allows for predictions as to treatment efficacy, and patient prognosis; obligations to inform patients and third parties of risk created by contagious disease and other sources of harm; obligations of physicians to disclose risks that the provider creates for the patient; obligations to disclose conflicts of interest arising out of the practice setting; and duties arising from new epidemiological knowledge. (shrink)

Kidney markets are prohibited in principle because they are assumed to undermine the seller’s dignity. Considering the trade-off between saving more lives by introducing regulated kidney markets and preserving the seller’s dignity, we argue that it is advisable to demand that citizens restrain their own moral judgements and not interfere with the judgements of those who are willing to sell a kidney. We also argue that it is advisable not only to limit the political implications of the moral argument of (...) dignity concerns toward a market-based solution but also to re-evaluate the dignity argument itself. First, if the dignity argument is to be given normative force, it must also consider the dignity violation of the potential transplant recipient. Second, there seems to be no compelling notion of dignity that demonstrates why it is morally permissible to donate but not to sell a kidney. (shrink)

BackgroundMedical outliers present a medical, psychological, social, and economic challenge to the physicians who care for them. The determinism of Stoic thought is explored as an intellectual basis for the pursuit of a correct mental attitude that will provide aid and comfort to physicians who care for medical outliers, thus fostering continued physician engagement in their care.DiscussionThe Stoic topics of good, the preferable, the morally indifferent, living consistently, and appropriate actions are reviewed. Furthermore, Zeno's cardinal virtues of Justice, (...) Temperance, Bravery, and Wisdom are addressed, as are the Stoic passions of fear, lust, mental pain, and mental pleasure. These concepts must be understood by physicians if they are to comprehend and accept the Stoic view as it relates to having the proper attitude when caring for those with long-term and/or costly illnesses.SummaryPracticing physicians, especially those that are hospital based, and most assuredly those practicing critical care medicine, will be emotionally challenged by the medical outlier. A Stoic approach to such a social and psychological burden may be of benefit. (shrink)

The past two decades have seen the extensive privatisation and marketisation of health care in an ever reaching number of developing countries. Within this milieu, medical tourism is being promoted as a rational economic development strategy for some developing nations, and a makeshift solution to the escalating waiting lists and exorbitant costs of health care in developed nations. This paper explores the need to problematize medical tourism in order to move beyond one dimensional neoliberal discourses that have, to (...) date, dominated the arena. In this problematization, the paper discusses a range of understandings and uses of the term ‘medical tourism’ and situates it within the context of the neoliberal economic development of health care internationally. Drawing on theory from critical medical anthropology and health and human rights perspectives, the paper critically analyzes the assumed independence between the medical tourism industry and local populations facing critical health issues, where social, cultural and economic inequities are widening in terms of access, cost and quality of health care. Finally, medical tourism is examined in the local context of India, critiquing the increasingly indistinct roles played by government and private sectors, whilst linking these shifts to global market forces. (shrink)

In response to rapidly rising health care costs in the United States, federal and state governments and private industry are instituting numerous and diverse cost-containment plans. As devices for coping with a scarcity of resources, such plans present serious challenges to physicians' traditional single-minded devotion to patient welfare. Those which contain costs by directly limiting medical options or by controlling physicians' daily clinical decisions can threaten the quality of medical care by allowing economic authorities to make essentially (...) medical judgments. In contrast, other plans coax compliance by arranging incentives, e.g., offering financial rewards for successful cost containment. While they allow for clinical freedom, these plans create conflicts between physicians' fiduciary obligations to their patients and the competing interests of the payers. Such conflicts arise as physicians try to work within governmental or corporate cost containment policies, and also as they attempt to streamline clinical efficiency. Throughout, issues of justice emerge as physicians seek to reconcile their own patients' claims upon limited common resources with others' equally legitimate claims. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Medical Tourism:Crossing Borders to Access Health CareHarriet Hutson Gray (bio) and Susan Cartier Poland (bio)Traveling abroad for one's health has a long history for the upper social classes who sought spas, mineral baths, innovative therapies, and the fair climate of the Mediterranean as destinations to improve their health. The newest trend in the first decade of the twenty-first century has the middle class traveling from developed countries to (...) those with emerging economies to avoid treatment delays, prohibitive costs for life-saving procedures, or simply high costs for elective surgery. Others leave to have access to assisted suicide in countries that have legalized it: Belgium, The Netherlands, and Switzerland. This new era of globalization in health care has arrived without the benefit of international standards, government oversight, or ethical and legal review.Howard Staab, a self-employed carpenter from North Carolina, flew to India for his medically necessary heart surgery, scheduled a side trip to the Taj Mahal, and returned home to work in North Carolina. He spent a total of less than $10,000, instead of the $200,000 required from the local hospital (I, Milstein and Smith 2006).At first blush, the outsourcing of medical care to India seems to be a particular solution for a particular problem. However, the particularity of Mr. Staab is not unique. His experience is emblematic of those patients in the United States with a medical need for major and elective procedures, but who also must bear the total cost of these procedures. These middle-class, under-insured Americans go abroad.In tandem with increasingly aggressive marketing campaigns, American hospitals and companies have begun to leverage their connections in Asia to grow the medical tourism business into a major economic force. What are the consequences of this?Several authors point to the effect on the host country's population, particularly the poor, to be pushed farther down the queue to receive adequate, affordable care. Resources are applied to the foreign trade instead of building the local [End Page 193] medical infrastructure. Another potential problem is the obligation of the home-country physician to provide follow-up care. What are the legal ramifications when the procedure was illegal to begin with? Are there opportunities for redress for medical errors?These factors may be converging into a "perfect storm" for health care in the U.S., in which the potential participation of the major insurance companies in promoting offshore care will be the tipping point in the precarious structure that represents the economic currents in health care. Third-party administrators and self-funded employers may be on the cutting edge in 2009 by providing incentives to employees to travel overseas for care.I. Economic ConsiderationsConnell, John. Medical Tourism: Sea, Sun, Sand and... Surgery. Tourism Management 27: 1093–1100, 2006.As evidence of the interest of traditional tour operators in this newer twist on the industry, the author explores medical tourism as an element of the growth of world tourism. In promoting medical tourism, he urges consideration of such issues as the privatization of health care, the foundational role of technology, and uneven access to health resources.Dunn, Philip. Medical Tourism Takes Flight. H and HN: Hospitals and Health Networks: 40–44, November 2007.Writing for U.S. health care executives, Dunn emphasizes that the reality of medical tourism competes with the local medical center for patients and their insurance dollars in a significant way. He examines the possibility that U.S. insurance plans soon may offer to pay for what is currently a cash only business and that the economic impact to the local medical center could be significant or even devastating.Frontiers of Health Services Management [Selected Articles] 24 (2), Winter 2007.In "Managing Healthcare Services in the Global Marketplace" (pp. 3–18), Bruce J. Fried and Dean M. Harris consider legal, ethical, and financial implications of the international workforce. In "Globalization of Health Care" (pp. 19–30), Lynn Schroth and Ruthy Khawahja point out that the transfer of comprehensive management expertise and intellectual property from U.S. medical centers to international sites is driving the success of collaboration between U.S. and foreign health care centers. In "Is... (shrink)