Ethics Conflicts In Rural Communities: Allocation Of .
chapter 9Ethics Conflicts inRural Communities:Allocation ofScarce ResourcesPaul B. Gardent, Susan A. Reeves
DisclaimerDartmouth Medical School’s Department of Community and FamilyMedicine, the editor, and the authors of the Handbook for Rural HealthCare Ethics are pleased to grant use of these materials without chargeproviding that appropriate acknowledgement is given. Any alterations tothe documents for local suitability are acceptable. All users are limited toone’s own use and not for resale.Every effort has been made in preparing the Handbook to provideaccurate and up-to-date information that is in accord with acceptedstandards and practice. Nevertheless, the editor and authors can makeno warranties that the information contained herein is totally free fromerror, not least because clinical standards are constantly changing throughresearch and regulation. The authors and editor therefore disclaim allliability for direct or consequential damages resulting from the use ofmaterial contained in this book.Although many of the case studies contained in the Handbook are drawnfrom actual events, every effort has been made to disguise the identitiesand the organizations involved.The Handbook for Rural Health Care Ethics provides general ethicsinformation and guidance. Due to complexities and constant changes inthe law, exceptions to general principles of law, and variations of statelaws, health care professionals should seek specific legal counsel andadvice before acting on any legal-related, health care ethics issue.Additionally, we have sought to ensure that the URLs for external Websites referred to in the Handbook are correct and active at the time ofplacing this material on the home Web site. However, the editor has noresponsibility for the Web sites and can make no guarantee that a site willremain live or that the content is or will remain appropriate.Handbook for Rural Health Care Ethics:A Practical Guide for ProfessionalsDartmouth College PressPublished by University Press of New EnglandOne Court Street, Suite 250, Lebanon NH 03766www.upne.comCopyright 2009 Trustees of Dartmouth College, Hanover, NHEdited by William A. NelsonCover and text design by Three Monkeys Design WorksSupported by NIH National Library of Medicine Grant # 5G13LM009017-02
Chapter 9Ethics Conflicts in Rural Communities:Allocation of Scarce ResourcesPaul B. Gardent, Susan A. ReevesABSTRACTAllocation of scarce resources is a reality for health care professionalsand organizations. Resource allocation issues can be particularlychallenging for rural communities, where resources are not enough tomeet all needs and fewer alternatives exist to resolve conflicts betweencompeting needs. In addition, the ramifications of decisions maybe more visible in the rural setting. Decisions regarding allocation ofresources can be troubling for clinicians and administrators to make,at both the personal and professional levels. Such decisions can beat odds with providers’ deeply held beliefs about benefiting otherswithout harm. Resource allocation decisions can create conflicts forpersonal, professional, organizational, and community priorities andcommitments. Though resource allocation issues are economic innature, they inherently raise issues relating to organizational missionand ethics. The philosophical method chosen to resolve resourceallocation conflicts can influence both the way in which decisionsare framed, and how the decisions are made. When responding toresource allocation conflicts, it is difficult to prioritize and identify aprimary fiduciary duty or responsibility. Resource allocation conflictsare characterized by multiple constituencies, complex relationships,and myriad benefits and harms—which may or may not be apparent.All of these factors make resolving ethics conflicts related to scarceresources in rural settings both difficult and emotionally troubling.
Allocation of Scarce Resources167CASE STUDIESCase 9.1 Granite Hospital budget restrictionsGranite Hospital owns and operates a small, two-provider primarycare practice in a community 25 miles from its main campus.Within the remote practice, two highly regarded family medicinepractitioners provide practically all of the primary care to thesmall town. The hospital has received numerous commentsover the years, attesting to the quality of the physicians and thesecure feeling that is provided by their presence. The hospitaloriginally established the primary care practice at the edge of itsservice area in response to anticipated capitation contracts thatnever materialized. Granite Hospital serves a large geographicalarea that has a low population, and the facility has receivedaccolades and awards for its efforts to meet community healthneeds and offer preventive services to residents. The hospital isnot strong financially, but has been able to subsidize its primarycare businesses with extra income from its acute care services.Recently, deep Medicaid reimbursement cuts have negativelyimpacted the financial condition of the hospital and, in response,the Board of Trustees and administration have had to considercutting operating costs. Questions have been raised about thehospital’s ability to continue to subsidize the distant primary carepractice. Board members are distressed by the devastating impactsuch a decision could have on the small town. Of course, if thecommunity were to find out, they too would be devastated, andtheir anger might create a PR nightmare for the hospital.Case 9.2 Moving procedures from hospital to officeDr. Patel is a general surgeon in a rural community. He has seen hisfinancial situation slowly deteriorate over the last several years, dueto reduced reimbursement. He currently does many proceduresin the small hospital’s operating rooms, despite the fact that theycould be done adequately in an office-based procedure area. Dr.Patel is thinking of moving the procedures to his office where hewould receive greater reimbursement. The hospital administrator is
168Common Ethics Issues in Rural Communitiesvery upset because the hospital relies on this revenue to supportcharity care and primary care services for the community. Dr. Patelunderstands this, but feels a financial obligation to his family. Healso feels that the hospital has other opportunities to regain lostrevenue. Finally, he believes he could charge less than the hospital,and thereby more directly benefit his patients.OVERVIEW OF ETHICs ISSUESDespite the fact that we live in one of the wealthiest nations in theworld, the access to adequate health care continues to challenge manycommunities. These challenges are often magnified in economicallydisadvantaged geographic locales. For example, rural communities, inparticular, struggle to recruit and retain qualified health professionalswho are capable of providing basic health services to residents.Rare is the rural health care professional who believes that there areadequate resources available to meet the demands for patient care.Decisions regarding the allocation of scarce resources are part of theeveryday work life of rural health care professionals. Such decisions areoften troubling, as they often result in the creation of “haves and havenots.” The majority of health care professionals, who by definition havechosen to devote their careers to meeting the health care needs ofothers, are driven by a strong sense of beneficence. These are individualswho possess strongly ingrained personal and professional values. Suchvalues are often enhanced during professional education, which dictatesthat harming or wronging others is to be avoided at any cost. Thisphilosophy can include a belief in the right of all individuals to neededhealth services. The professional’s inability to provide adequate healthcare services to all residents of the community may cause him or her tosuffer moral distress. Therefore, the provider’s need to consider allocatingscarce resources can create conflict between deeply ingrained valuesand the realities of modern hospital financing in an era of managed care.1Resource Allocation Decision-MakingThe first step in ethical decision-making involves identifying the nature ofthe conflict that surrounds the allocation of scarce resources. The natureof such conflicts can be described in a conflict typology along two
Allocation of Scarce Resources169dimensions, the focus of moral conflict and locus of values, shown inFigure 9.1. Such value conflicts are often expressed by citing principlesof obligation, loyalty, and duty to others.Figure 9.1Allocation of Scarce Resources Conflict MatrixLocus of Values (Perceived Obligation, Loyalty or Duty)Focus ofConflictPersonalProfessional OrganizationalCommunityStakeholder 1Stakeholder 2Stakeholder 3The “locus of values” may manifest among any combination of personal,professional, organizational, and community values. Deeply held beliefstypically express themselves as personal values, which often are a resultof faith, culture, upbringing, and life experiences. Professional valuesare expressed as professional Codes of Ethics in medicine, nursing andother health professions, and become ingrained during the individual’sprofessional development and formation (e.g., American MedicalAssociation Ethics Manual; Code of Ethics for Nurses; American Collegeof Healthcare Executives’ Code of Ethics). Organizational values areexpressed through the sense of obligation felt to an organization. Thesevalues often relate to an individual’s sense of responsibility for supportingthe organization’s mission, value statements, and policies. Finally, andparticularly for people living or working in rural communities, there canbe a deep cultural sense of dedication and obligation to the community.The focus of the ethics conflict is on the competing values of the variousstakeholders. The stakeholder conflict can be an internal personal conflict;a conflict among professionals; a conflict between professionals and theorganization; a conflict between the organization and the community, orsome combination of these. A personal conflict may be experienced whenan individual is confronted with trying to adhere to competing values.
170Common Ethics Issues in Rural CommunitiesInter-professional conflicts occur among and between professionalsdue to conflicting personal moral principles or while trying to adhere tovalues held within a different locus. Often conflicts are heightened whenthe priorities between these dimensions vary among the professionalsinvolved in decisions regarding allocation of scarce resources.Frequently, trying to allocate limited resources becomes a problem ofdeciding how to rank the various competing values within the context ofthe organization’s priorities. A suggested ranking is outlined in Box 9.1.Box 9.1Priority Ranking of Competing Organizational Values Patient’s quality of care Professional excellence Organization’s financial stabilityProfessor Werhane has noted that the stakeholder theory of decisionmaking should drive the reflection process for ethical decisionmaking done by health care organizations, in cases when there arecompeting values within the context of organizational decisions. Thestakeholder theory, she writes, “ argues that the goal of any firm andits management is, or should be, the flourishing of the firm and all (of) itsprimary stakeholders,”2 as compared to a goal of maximizing the welfareof the shareholders. This line of priority setting would require that theprimary mission of the health care facility be to provide quality patientcare. Therefore, excellence in patient care is the first priority. Becausethe integrity, and possibly the survival of the organization, is dependenton the professional’s ability to offer competent, quality care, the staffwould be the second priority. The third priority would be the long-termorganizational viability, including its financial stability.2The process of applying Werhane’s proposed priorities is complicatedby the fact that specific situations vary. For example, an acute financialcrisis may require heightened attention to the organization’s financialpriorities. The proposed ranking is not an absolute algorithm. But it canprovide a starting point for providers and administrators to reflect and
Allocation of Scarce Resources171discuss the concept of setting priorities, such as in situations whenthe “locus of values” matrix highlights stakeholder differences, e.g. inconflicts between personal and organizational values.General Ethics Approaches for ConsiderationDespite the proposed priority ranking of competing values, there is noquick answer to the problem of inadequate health care resources. Conflicts surrounding allocating resources will continue to be a reality for thosecharged with the distribution of available resources. Therefore, the questions become: What approach should be the basis for allocation decisions? What type of process would be best used to mitigate the negativeimpact of such decisions? And are there strategies to reduce the inevitablemoral distress perceived by those with decision-making responsibilities?The philosophical approach chosen by providers and administratorsto resolve resource allocation conflicts can impact both the waydecisions are resolved and how decision-making is approached. Forexample, the health professional may use a utilitarian approach (basedon the theory that if an action or practice is right, when compared toan alternative action, it leads to the greatest possible balance of goodconsequences), which would call for the delineation of derived benefitsby the recipients, with a choice to favor the decision that ultimatelybenefited the most people.3 Such philosophical approaches tend toleave out disadvantaged groups with small numbers (e.g., a small townor an individual practitioner).A “communitarian” approach is used to derive decisions which benefitthe community as a whole over decisions that benefit individuals.4 Eachof the cases introduces the complexity of defining “community.” Forexample, the community of interest for the Granite Hospital is the patientpopulation it serves, comprising several towns around the hospital,whereas the remote small town that would be impacted by the primarycare center closure is defined much more narrowly. For the practicingclinician, the community of interest may be even more restricted. Again,it is important to be clear around the definition of “community.”Deontological approaches, unlike utilitarianism, are used to decide whatis right according to a duty to basic beliefs. These types of approaches
172Common Ethics Issues in Rural Communitiesare expedient, but often ill-suited for providers to apply to resourceallocation issues, because of the focus on an action’s intent rather thanits result.5 Deontological approaches by nature are contextual, and theyoften fail to resolve conflicts among competing values. As such, theapplication of this type of ethics approach is difficult.Health Care Ethical PrinciplesIn addition to the general ethics theories just discussed (philosophical,communitarian, utilitarian and deontological approaches) there arewidely accepted and applied health care ethical principles, which includebeneficence, nonmaleficence, autonomy, justice, veracity, and fidelity4, 6—all discussed in Chapter 3. These principles are frequently captured ina hospital’s mission, vision and values statements, as well as in the staffpractice standards.The principles of veracity (honesty), fidelity (loyalty), and justice arealso embedded into many resource allocation cases, including thosepresented here. The various providers and the hospital have manyloyalties. The plight of the individual physician who attempts to jugglepersonal, professional, community and organizational loyalties isparticularly difficult. Hospitals are torn between serving the communityand surviving in a business market, and thus may not always becompletely honest with the community. When designating programsor funds, honesty is typically the best policy, particularly when financialsituations change. An “honesty” policy will reduce the amount of publicrelations backpedaling that the hospital will need to do if programsmust be cut. For example, Granite Hospital may have entered theremote community market as a business strategy, with the intent tomake a profit, but likely did not communicate the establishment ofthe practice as such to the local townspeople. It is more likely thatthe strategy was described as one that fulfilled the hospital’s caremission. While both strategies are likely true, the marketing of the clinicestablishment may have been less than forthcoming.When confronting decisions regarding the allocation of necessary yetscarce resources, a number of moral issues are raised that challengethese core principles. Such decisions often challenge a provider’svalues and beliefs about what is morally right and wrong, particularly
Allocation of Scarce Resources173in situations where there are no good alternatives. The resulting moraldistress can be debilitating to the decision-maker. And, such distresscan be divisive and destructive within organizations and communities.So what happens when there are both good and harmful effects of suchdecisions? How does one decide what is the right thing to do?Decision-Making Methodologies for SituationsThat Involve Scarce Resource AllocationMaking decisions in situations where scarce resources must be allocated is inherently difficult, and often challenges the clinician’s desire to dowhat is right. The methods that providers use to make such decisions,including cost/benefit calculations, can be helpful in resolving allocationissues, although they do not entirely resolve providers’ feelings of moraldistress. In cost/benefit calculations, the clinician or administrator mustfirst identify all the parties who may be involved and impacted by a decision. Ideally, representatives of the various parties would contribute tothe cost-benefit discussion process to gain the best and most comprehensive inventory of costs and benefits. A listing of the costs and benefits that accrue to each of the parties should be clearly identified, takingcare to include costs and benefits that are non-financial in nature. Relative measures of risk/harm and benefit/good should be made as objective and quantifiable as possible. Often, the use of a skilled facilitator towork with the various parties is a useful adjunct to this type of process.The decision-making team should always conduct a further evaluationafter an open and inclusive cost/benefit analysis. Their evaluation shouldexamine whether a severely disadvantaged or marginalized group hasborne a disproportionate burden of harm or cost as the result of thedecision. Members of such groups, and their needs, are often poorlyrepresented in medical decision-making processes. For example,Granite Hospital might argue that it is preferable to require the citizens ofthe remote community to drive the 25 miles to the hospital for services,as opposed to having the hospital go out of business all together.But for members of a disadvantaged group (e.g., those without anytransportation), there is little difference between losing their primary carepractice and being able to access the hospital, as the hospital wouldeffectively be inaccessible to them.
174Common Ethics Issues in Rural CommunitiesWhen confronted with allocation decisions, the concept of distributivejustice can be employed in a manner that allows the allocationmethodology to promote equity and fairness.5 While there are variousmethodologies that health care management can apply in decisionmaking, transparency is essential when choosing the type of methodology,and the consistent application of that methodology. Potential justicedistribution methodologies include those listed in Box 9.2.Box 9.2Potential Justice Distribution Methodologies3 To each person an equal shareTo each per
CHAPTER 9 Ethics Conflicts in Rural Communities: allocation of scarce resources Paul B. Gardent, Susan A. Reeves aBsTracT Allocation of scarce resources is a reality for health care professionals and organizations. Resource allocation issues can be particularly challenging for rural communities, where resources are not enough to
999 battle deaths, while conflicts resulting in 1,000 or more battle deaths are coded as major civil wars. As most contemporary conflicts are intrastate conflicts, this paper focuses mainly on these. Uppsala classifies violent conflict in three different categories: 1) state-based armed conflicts, 2) non-state conflicts and 3) episodes of one-sided violence.While “state-based armed conflicts .
scale of public library services. They bring books to rural folk where there is no library service; they also provide resource persons and supervisors of reading centres to the communities, especially to rural communities. Rural Communities and Rural Libraries A rural library is a library or library system that serves a rural community or .
Law and Public Safety pursuant to N.J.S.A. 52:13D-21. "Conflicts Law" means the New Jersey Conflicts of Interest Law, N.J.S.A. 52:13D-12 et seq. "Ethics Liaison Officer" means the individual(s) designated by the agency head to assist the State Ethics Commission in implementing and enforcing the Conflicts Law and related ethics codes.
Sampling for the Ethics in Social Research study The Ethics in Social Research fieldwork 1.3 Structure of the report 2. TALKING ABOUT ETHICS 14 2.1 The approach taken in the study 2.2 Participants' early thoughts about ethics 2.2.1 Initial definitions of ethics 2.2.2 Ethics as applied to research 2.3 Mapping ethics through experiences of .
The Conflict of Interest-Guidebook to Practice Forms and Letter provides sample documents to manage conflicts and potential conflicts. MLM’s Law Practice Management Booklet Series, Avoiding Conflicts of Interest offers information to help you identify, check for and manage conflicts of interest situations.
"usiness ethics" versus "ethics": a false dichotomy "usiness decisions versus ethics" Business ethics frequently frames things out, including ethics Framing everything in terms of the "bottom line" Safety, quality, honesty are outside consideration. There is no time for ethics.
Code of Ethics The Code of Ethics defines the standards and the procedures by which the Ethics Committee operates.! More broadly, the Code of Ethics is designed to give AAPM Members an ethical compass to guide the conduct of their professional affairs.! TG-109! Code of Ethics The Code of Ethics in its current form was approved in
Advanced Management Accounting CIMA (P2) The best things in life are free To benefit from these notes you must watch the free lectures on the OpenTuition website in which we explain and expand on the topics covered. In addition question practice is vital!! You must obtain a current edition of a Revision / Exam Kit - the CIMA approved publisher is Kaplan. It contains a great number of exam .
