Is the American healthcare system unethical?

Health Care Ethics: Quality of Treatment - Top Priority

THEMES OF THE TIME

Krüger, Carsten; Rapp, Boris

Today, the economy has largely supplanted the medical ethos and the care of nursing. Photo: Peter Wirtz
Hospitals are forced to reconcile the demands of business and ethics.

In addition to the previously predominantly religious care of nursing and the medical ethos, the largely dominant economy has now found its way into the health system. As a result, there is an increasing conflict between economics and ethics in the hospital. In fact, it is a clash of two divergent moral concepts: the deontological moral concept, which is mostly represented by the professional groups close to the patient, and the teleological or utilitarian moral concept, which is more embodied by the actors remote from the patient. Since the social sciences have not yet developed a combined, substitute moral theory, the two moral concepts are not compatible with one another. Economic efficiency and ethics, on the other hand, are by no means incompatible. On the contrary: they are mutually dependent if a hospital wants to be successful in the long term in competition. On the one hand, the waste of resources is unethical because these funds could finance better treatment. On the other hand, the hospital must meet the ethical requirements in order to guarantee the high quality of treatment required in competition.
Deontology (Greek: todeon, the necessary, the duty) is a theoretical approach that sees the strict observance of norms, duties and rights as the basis of moral action. Laws can be derived from the normative specifications. Immanuel Kant, the most important proponent of this theoretical approach, coined the term categorical imperative in this context: "Only act according to the maxim by which you can also want it to become a general law." evil, about right and wrong. Any deviation is not virtuous and therefore immoral. In contrast to other economic sectors, the deontological approach is still strongly represented in hospitals, albeit mostly unconsciously. It is primarily embodied by the patient-related staff groups.
In teleology, the moral value of an action does not lie in the morality of the action itself, but results from the consequences of the action for the general public. Teleology underlies utilitarianism. The decision as to whether an action is moral, good, and moral is related to the benefits that result from it. So it is possible that a decision to act may be made at the expense of the well-being of individuals and in favor of the well-being of the majority. The typical representatives of the utilitarian view are the groups remote from the patient. These include hospital management, politics and health insurance companies. All three groups have to make decisions for the good of the community. You have to generate optimal performance with scarce resources. Decisions are made according to the teleological principle at the expense of individual cases.
This is exactly where the basic conflict between the deontological and utilitarian theoretical approaches lies. From the deontological point of view, a decision that harms someone is immoral. It only looks at individual relationships and sees moral action in it as the highest duty. This creates a dilemma because the intentions of the norms in healthcare today are utilitarian. The will to act in a deontologically moral manner is restricted by legal requirements.
Increase in the competitive situation
The basic conflict can be seen in numerous hospital situations, but especially with rationing and rationalization. One form of rationing is the budget and the DRG flat rate system. To maximize profits, the hospital needs to cut costs or generate additional income in other areas. The hospital is forced to rationalize and streamline its cost structures through the DRG case flat rates, because the previously profit-driving factor of long hospital stays has turned into the opposite. The shorter the patient's stay, the more profitable the treatment is. The economic requirement of the hospital is therefore to increase the efficiency and productivity of the treatment and to optimize the treatment processes. Shortening the length of stay without increasing the number of cases results in overcapacities. These cause intensified competition for customers between hospitals. Because of this competition, the primary economic goal of management is to secure the hospital's existence.
As long as the social sciences fail to develop a mixed theory of duties in terms of the substitution principle from the two moral concepts existing in the hospital, the hospital should create the best possible consensus that equally fulfills both moral concepts. This means that it is the task of the hospital management to create conditions under which the purposeful, utilitarian decisions do not collide with the moral understanding of the staff close to the patient. Applied to the practice, this means that the quality of treatment must have priority. Only when the quality of treatment is optimal does the nursing profession and the medical profession not ask about the
moral choice between economy and ethics. Making such moral decisions makes the workforce feel that health care problems are on their backs
would. This perceived impotence can lead to demotivation and high turnover and is for the
Treatment quality counterproductive.
The increase in competition among hospitals increases the need for economic competence and purposeful thinking. This undoubtedly harbors the risk of widening the gap between the representatives of the different moral concepts. It is therefore important to meet the ethical requirements in addition to the economic requirements, because without the involvement of groups close to the patient, treatment quality and thus a high reputation of the hospital cannot be achieved.
A modern hospital is forced to reconcile the requirements of economic efficiency and ethics in order to ensure sustainable success. Some concepts meet these premises. In the area of ​​human resources, the ethical-economic conflict can be made clear. Health care is a labor-intensive area. With an average of 70 percent, personnel costs represent the largest share of costs in hospitals. This is also the reason why staff reductions are often considered first when rationalizing. The quality of treatment also depends on the number of staff. Therefore, professionalization in personnel management is necessary. The most important tasks are the creation of a personnel requirement plan and the reorganization of work processes. In the case of process optimization, the job descriptions must be adapted to the circumstances or new professional fields must be created. The employment of hotel specialists could lead to an improvement of the service concept in the sense of a customer orientation. The economic requirements make the position of a controller unavoidable and make the concepts of coding specialists seem extremely useful.
Case managers ensure that workflows are optimized
Case managers can ensure smooth and fast scheduling, including clarifying the conditions for discharge or transfer (transitional care, rehabilitation place, outpatient care, placement in care facilities). The quality is indirectly improved by the case companion. Medical technology also requires ongoing training for specialist staff. A further improvement can be achieved through systematic personnel appraisal, whereby the employees can be deployed in the right positions according to their skills. In addition, career planning is a performance incentive for employees. Attractive future career prospects could prevent ambitious employees from leaving. For this reason, new job profiles should be created that adapt from the level of the job to the level of training. In this regard, hospital management is calling for a reform of the rigid collective bargaining agreements in the public sector. These prevent performance-based pay that is conducive to performance and the creation of new organizational structures that enable better opportunities for advancement. The new professional fields in particular lead to problems. The current tariff system makes the public hospital financially unattractive for controllers and computer specialists, for example. The dichotomy is clearly visible. On the one hand, a modern hospital needs a high quality of treatment in order to remain competitive, which means an increase in personnel costs due to the required employment and further training of qualified personnel. On the other hand, the general conditions are forcing costs to be reduced due to competitive pressure.
In order to be able to afford the luxury of well-trained staff, it is necessary to optimize the service processes and thereby save costs. One possibility is the standardization of patient-oriented treatment processes. As a result, this means an even shorter length of stay with high-quality care. The increase in information gives the patient security and trust and makes the process controllable and qualitatively more assessable for him. In this way, the patient is integrated into the treatment team. The aim is to increase patient and employee satisfaction. The satisfaction of the employees results, for example, from the quality of the treatment, the smooth process and, last but not least, from the satisfaction of the patients. Savings result from the shortening of the length of stay, the avoidance of double examinations and the reduction of resources to the necessary requirements. The concepts and rationalization options shown show that it is possible to combine ethical and economic requirements in a profitable way.

How this article is cited:
Dtsch Arztebl 2006; 103 (6): A 320-2.


Literature on the Internet: www.aerzteblatt.de/lit0606

Addresses of the authors:
Carsten Kruger
Suhrenkamp 22 b
22335 Hamburg
Email: [email protected]
Dr. Boris Rapp
MediClin AG, Strategic Planning
Okenstrasse 27
77652 Offenburg
Email: [email protected]
Damkowski, Wulf; Meyer-Pannwitt, Ulrich; Precht, Claus: The changing hospital: Concepts, strategies, solutions, Kohlhammer, Stuttgart, Berlin, Cologne 2000
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Korff, Wilhelm, inter alia: Handbook of Business Ethics, Volume 1: Determining the relationship between business and ethics, Gütersloher Verlagshaus, Gütersloh 1999
Korff, Wilhelm, inter alia: Handbook of Business Ethics, Volume 4: Ethics of Economic Action, Gütersloher Verlagshaus, Gütersloh 1999
Lohmann, Heinz; Wehkamp, ​​Karl-Heinz (Ed.): Vision Gesundheit, Volume 1: Health enterprise: The LBK model, WIKOM-Verlag, Wegscheid, 2002
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1. Damkowski, Wulf; Meyer-Pannwitt, Ulrich; Precht, Claus: The changing hospital: Concepts, strategies, solutions, Kohlhammer, Stuttgart, Berlin, Cologne 2000
2. Dibelius, Olivia; Arndt, Marianne (ed.) And others, Nursing Management Between Ethics and Economy: A European Perspective, Schlütersche Verlag, Hanover 2003
3. Korff, Wilhelm, inter alia: Handbook of Business Ethics, Volume 1: Determining the relationship between business and ethics, Gütersloher Verlagshaus, Gütersloh 1999
4. Korff, Wilhelm, inter alia: Handbook of Business Ethics, Volume 4: Ethics of Economic Action, Gütersloher Verlagshaus, Gütersloh 1999
5. Lohmann, Heinz; Wehkamp, ​​Karl-Heinz (Ed.): Vision Gesundheit, Volume 1: Health enterprise: The LBK model, WIKOM-Verlag, Wegscheid, 2002
6. Pföhler, Wolfgang: Compulsion to economic action and humanity in the hospital: an insurmountable contradiction ?, in: Das Krankenhaus, Kohlhammer, 90th year, number 12, 1998
7. Wehkamp, ​​Karl-Heinz: The ethics of the health professions and the challenges of the economy, 1st edition, Humanitas-Verlag, Dortmund 2004
8. Wilken, Udo (Ed.), Social work between ethics and economy, Lambertus-Verlag, Freiburg im Breisgau 2000
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