Reforming healthcare: an ethical
perspective
Health care schizophrenia
I don’t care how
much it costs, I
want the best care
available.
It costs what?
That’s outrageous!
Everyone in
America should
have appropriate
access to health
care.
I am not willing
to pay any more
taxes, and I don’t
want socialized
medicine.
Government
should fix it.
Let the market
fix it.
Here is the real bottom line: The current state of
health care is unethical. It is neither just nor fair.
There is no morally defensible reason why some
Americans get excellent medical care at costs they
can afford and other Americans lose their homes or
go into bankruptcy attempting to secure treatment for
a seriously ill loved one. The current proposals being
debated in Congress all go a long way towards
making health care in America more just. At the same
time, there is nothing in the current proposals that
threatens a patient’s right to choose, a critical feature
of an ethically acceptable health care system.
- Ruth Faden
ethics of health reform
"This historic legislation, for the first time, enshrines a
national commitment to guarantee that all of us in
this country have meaningful access to appropriate
medical care. As a consequence, our society is now
more just. Our people have a greater prospect of
securing for themselves and their families not only
more health, but also more of everything that is
essential to human well-being, including personal
security, respect and self determination.“
- Ruth Faden
ethics of health reform
“examination of the issues in healthcare
reform would require consideration of much
different arguments than already presented.
ethical issues would center on the moral
right discussion and would begin with not
“what is best for me” but rather “how should
we as a society be acting so that our actions
are morally correct”
- Beverly O’Malley
ethics of health reform
What neither side will admit is that medical
rationing is part of the future. We can't
afford a system where everybody gets
whatever care they want regardless of
cost and effectiveness. The only question
is whether we'll ration intelligently and
fairly, or not.
- Beverly O’Malley
ethics of health reform
However, all ethical decision making is structured
around values. In order for universal health care
to be embraced by all citizens in the United
States, they will first have to agree to the
collective value of equity and fairness and
embrace the goal of meeting their collective
responsibility to each other while maintaining
individual rights and freedoms. That may prove
to be the most difficult obstacle of all.
- Beverly O’Malley
ethics of health reform
When a third party— government, insurer or
employer—controls most of the health care funds,
that entity eventually becomes the decision maker,
not the patient.
An ethical health care system doesn’t just promise
people they will get the care they need, it empowers
people so they can get that care.
- Merrill Matthews. PhD
Institute for Policy Innovation
ethics of health reform
What action will bring the most good to the
most people?
What action in and of itself is a good act and
helps us to fulfill our duties, obligations, and
responsibilities to each other?
What action in and of itself shows caring and
concern for all citizens?
reform in
america
1
9
4
0
s
employer-sponsored health care
1
9
6
0
s
government-sponsored health care
To provide coverage
for the elderly as
well as poor women
and children,
Congress enacted
Medicare &
Medicaid in the mid1960s.
1
9
8
0
s
health care for all…through
an unfunded mandate
The Emergency Medical Treatment and Active
Labor Act (EMTALA) of 1986 requires
hospitals to screen and stabilize (treat) every
patient who comes to the hospital ED seeking
care, regardless of the patient’s ability to pay
and regardless of what it costs the hospital to
provide the care.
2
0
1
0
the affordable care act
3 key myths about health reform
 health reform means giving up control
of my own healthcare decisions
 health reform will control healthcare
costs by depriving patients of important
but costly medical treatments
 health reform will deny older Americans
medical treatment at end of life
strategic directions
• coverage
• delivery system
reforms
• payment reforms
• transparency
• health IT
National Priorities Partnership:
Overarching Objectives
• Improve the safety and reliability of America’s
health care system
• Engage patients and families in managing health and
making decisions about care
• Ensure patients receive well-coordinated care across
all providers, settings, and levels of care
• Guarantee appropriate and compassionate care for
patients with life-limiting illnesses
• Improve the health of the population
• Eliminate waste while ensuring the delivery of
appropriate care
implications for hospitals
• achieve solid hospital-physician
(clinical) alignment
• measure, report and deliver
superior outcomes
• reduce costs
• form strategic alliances
implications for physicians
• apply evidence-based practices
to achieve best clinical results
• deliver the right care…at the
least cost
• coordinate your patients’ care
with other providers
• learn to manage risk in
partnership with hospital and
physician colleagues
Percent Seeing 10 or More Different Physicians
during the Last Six Months of Life
Percent of Deaths Occurring In Hospital
Percent of Cancer Patients Dying in Hospital
Percent of Decedents Enrolled In Hospice
during the Last Six Months of Life
Guiding Ethical Principles
Beneficence- obligation to benefit
patient and to further their welfare and
interests
 Respect for autonomy- protect and
defend the informed choices of capable
patients
 Nonmaleficence- obligation to prevent
or minimize risk of harm
 Justice- fairness of access to health care

Ethical Obligations of Clinicians
Respect patient’s rights/autonomy and
maintain confidentiality
 Communicate honestly about patient’s
diagnosis, treatment and prognosis
 Determine patient’s decision making
capacity
 Actively participate in informed consent
process

Patient-Centered Care Continuum
Population
Health
Management
Chronic Disease
Management
Pharmacy
Specialists
Data
Management
LTACH &
Acute Rehab
Medical
Home
EH R
EH R
Home Care
Ancillary
Providers
Palliative Care
Patients
EHR
Long Term
Care
Hospitals
Public Health
Agencies
Hospice
27
Conceptual Shift from “Curative Model”
Life Prolonging Care
Medicare
Hospice
Benefit
Life Prolonging
Hospice Care
Care
Palliative Care
Diagnosis
28
Death
Old
New
Palliative Care Teams
Address 3 Domains
1. Physical, emotional, and spiritual distress
2. Patient-family-professional communication and
decision-making
3. Coordinated, communicated, continuity of care and
support for practical needs of both patients and
families across settings
‘Mainstreaming’ Palliative Care
 Providing palliative care simultaneously with
all other appropriate medical treatment
 Actively integrating palliative care into care
transition programs
 Expanding palliative care services and
resources across entire care continuum
 Demonstrating positive impact of palliative
care from a “triple aim” perspective
30
How Advance Directives and POLST Work Together
Adapted with permission from California POLST Education Program
© January 2010 Coalition for Compassionate Care of California
POLST: An outcomes
continuum
Better
informed
consent
+
Patient’s
documented
wishes
Patients’ wishes
known & honored
=
=
+
Family
consensus
Satisfaction &
communication
=
Hospice
LOS
=
Hospice & Palliative Care Utilization
Hospital
LOS
=
+
Portable
MD
orders
=
=
Risk &
Costs
Pain
management
SC Triple Aim Platform
33
Keys to a Healthy South Carolina
1. Health care must become highly reliable.
2. Patients must be more engaged.
3. We must deliver compassionate and
patient-centered care at the end of life.
4. We must improve health status and
reduce health disparities.
5. We must improve efficiency and reduce
waste.
6. We must improve coordination of care.
7. Payment models must be reformed and
aligned.
SC Coalition for the Care of
the Seriously Ill ( SC CSI)
• Founding Members: SCMA, SCHA, TCC, SC
Healthcare Ethics Network, LifePoint, AARP, SC Nurses
Association
• Mission: All persons in SC with serious, chronic, or
terminal illnesses will have an active voice in the care
decision process