Bursic 2:00
L03
MORALITY AND RESPONSIBILITY OF ENGINEERED HEALTHCARE
REFORM
Leah Kaighn (lek77@pitt.edu)
INTRODUCTION: CONSULTING
ENGINEERS TO REMEDY HEALTHCARE
CRISIS
The debate over healthcare in American political and
social culture is neither new nor does it have a foreseeable end
in sight. Conflicting opinions over who should pay the burden
of health costs, who is entitled to government benefits, and
who is allowed access to decent care will surely divide the
country for some time, yet the underlying belief remains the
same: our nation’s health system needs reform. While not at
the forefront of the discussion, a solution proposed by
professional engineers has both logic and science on its side.
Their resolution to healthcare problems lie in engineering
principles, namely systems and human factors engineering
[1]. The application of engineering techniques is crucial to
alleviating problems, namely those regarding high expenses
and inadequate safety measures, in healthcare because of the
benefits incurred from an efficient, effective, and engineered
network of participants [2]. Engineered healthcare is worthy
of high consideration because of the economic and social
benefits of a well-functioning arrangement of healthcare
components and the national focus on the current state of our
nation’s healthcare, yet engineers, like other professionals,
face the legal and moral bounds of laws and codes of ethics,
which must be considered when implementing large scale,
national reforms, such as the ones that will be proposed.
While healthcare specifics are organized, managed, and
executed by the components listed above, another entity plays
a major role in national healthcare: the federal government.
Legislative and executive components contribute to the
system by setting regulations, providing funding, and even
operating their own network of hospitals. Industrial and
systems engineers could be faced with an ethically charged
situation when dealing with the government and healthcare
reform. For example, because improving healthcare is at the
forefront of national discussion, particularly during the
current administration and economic crisis, congress and the
President may seek the professional advice of engineers on
how to remedy the issues of high costs and patient safety. A
team of engineers may be hired by the government to research
methods of healthcare system improvements, which it would
do by studying existing systems, past innovations, and current
proposed models. The team would then compose a
recommendation to the problem, and finally, take ethics into
consideration when reviewing the suggestion it makes,
making sure the recommendation is in line with standards set
by codes of ethics. All formalities of the arrangement are
University of Pittsburgh, Swanson School of Engineering 1
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ethical, meaning no individual or group tries to cover
information, provide false or misleading information, etc. For
this reason, the ethical situation lies in the actual task of the
group, specifically in the group’s reflection, which is crucial
because the project is on a high level, with the potential to
influence an entire country.
PROBLEMS AND RECOMMENDED
SOLUTIONS TO GOVERNMENT GOALS
The situation begins with the engineering team researching
the described problems in the American healthcare system.
As directed by the government, the engineers are to focus on
healthcare costs and patient safety. To begin, they find
statistics to get a clear picture on these alleged problems.
Their findings confirm that the system is broken and
disjointed. For example, health expenditures in the U.S. are
some of the highest in the world. The Organization for
Economic Co-Operation and Development, or OECD,
researches various aspects of different nations’ economies,
including healthcare spending. In 2011, the U.S. spent 17.7%
of its GDP on healthcare. Compared to other developed
nations, this number is high. For instance, Switzerland,
Austria, and Germany spent 11.3% or less of their GDP’s,
while the United Kingdom, Sweden, and Norway all kept
expenditures under 10% [3]. While other factors such as the
quality of care and the relationship between public and private
institutions contribute to how much a country spends on
healthcare, healthcare engineering experts W.B. Rouse and
D.A. Cortese assert that the differences in spending between
the United States and other developed countries is a problem
for our country because American healthcare is not better, as
measured by infant mortality and life expectancy, than many
other countries [2]. This disparity among spending highlights
the need for a cooperative system of components working
together to improve healthcare delivery.
Furthermore, another crucial problem regarding the
healthcare system is patient safety. Research into this topic
yielded a study analyzed by University of WisconsinMadison industrial engineer Pascale Carayon and medical
professor Kenneth E. Wood, which estimates that 44,000 to
98,000 Americans die every year from preventable medical
errors [2]. Errors that are preventable suggest a scenario in
which humans rather than science are at fault. This problem
is not one that can be remedied by doctors, but instead needs
the problem solving skills of engineers who find solutions to
problems occurring between workers and their environment.
These skills include the ability to see a medical network as a
system, rather than the individual components, and this
Leah Kaighn
viewpoint allows industrial and systems engineers to apply
their knowledge of integrated systems to improve quality and
efficiency in the healthcare system. To help diagnose and fix
this problem, Carayon developed the SEIPS model.
The SEIPS model was developed as a tool for industrial
and human factors engineers to clearly identify problems in a
systematic way, which can lead to controlled solutions,
backed by factual data [4]. In short, the model aims to connect
the work system (an organization’s structure), the process (the
means by which healthcare is executed), and the outcome
(patient safety) [4]. All of these components are connected,
and the study of their relationship as a whole system allows
engineers to properly identify causes and solutions to patient
safety problems. The SEIPS model expands on earlier
models, most notably Donabedian’s structure-processoutcome (SPO) model [4]. That model primarily analyzes
how human care is related to the process and patient outcome,
yet it overlooks how the structure of the process itself impacts
outcome [4]. Continued integration of healthcare systems,
combined with industrial engineering models will improve
the quality of healthcare in the United States. Specifically,
the SEIPS model will enhance patient safety, “by clearly
specifying the system components that can contribute to
causes and control of medical errors…showing the nature of
the interactions between the components” [4]. This model
emphasizes the interdependence of various components in a
system, such as physicians, pharmacists, researchers, and
management professionals, thus providing reason to integrate
different aspects of the healthcare network. The SEIPS model
is just one application of engineered healthcare, which is
specifically applied to patient safety. Yet, because of its
emphasis on component interactions, I think it can be applied
to effectively merge different parts of the healthcare network
such as clinics, hospitals, insurers, and patients. This can be
accomplished by making digital health records that can be
shared easily among doctors or minimizing wait times in
emergency rooms. This will help improve the United States’
healthcare system by reducing extraneous costs associated
with errors and bolster overall health among patients who
receive professional medical care.
Thus, the above research and the development of the
SEIPS model provide the engineering team with the tools it
needs to provide the government with a detailed report. It
suggests that integrating the healthcare network into a more
cooperative system that develops and progresses as one,
rather than individual components, and applying the SEIPS
model to hospitals and other health networks will help those
networks reduces costs and cultivate methods for improving
patient safety. This solution was backed by an overview of
studies based on engineered healthcare approaches, entitled
“Effects of Integrated Delivery System on Cost and Quality”,
which found that 19 out of 21 studies reviewed showed
improvements in healthcare quality when system components
are coordinated into a more comprehensive system [5].
INDIVIDUAL RELFECTION: COMPARING
RECOMMENDATIONS TO CODIFIED
ETHICS AND PERSONAL MORALS
When working on a group project, all members must work
together to ensure that the outcome is the most optimal one.
However, I believe that individuals must weigh the ethical
questions by themselves as well, to ensure that their own
morals and interpretations of ethical codes are upheld. In this
case, the exact ethical matters in question relate to whether or
not the suggestion is in line with national codes and if its
implementation will be executed in the manner intended by
the team of engineers. If I were an engineer working on this
project, I would first consult the National Society of
Professional Engineers’ Code of Ethics for Engineers. This
is the overarching code of ethics accepted by all American
engineering disciplines, which outlines fundamental canons
and explains in more detail rules of practice and professional
obligations of engineers [6]. I would look at this code when
deciding whether or not our suggestion is an optimal one
because it is universally accepted, thus providing a basis on
what is generally accepted in terms of engineering ethics. The
first canon states that engineers must “hold paramount the
safety, health, and welfare of the public” [6]. Because the
recommended solution was aimed at improving healthcare,
society as a whole will be benefitted, which in turn fulfills that
canon. In this situation, the engineering question was a matter
of making something “bad” into something “good”. Thus, a
code of ethics, which can often be vague, is a sufficient tool
for assessing a situation. The recommended solution ideally
creates a win-win situation for all parties involved (patient,
provider, and government) because costs are down and
quality is enhanced. This in turn leads to an indisputable
assertion: the overall safety, health, and welfare of the public
is better than before the changes.
Despite a simple code of ethics being sufficient for the
matter at hand, I would make sure my decision is sound by
consulting my own personal beliefs. My opinions and beliefs
have been shaped by my culture and upbringing. Therefore,
I would consult the people who understand these best: my
family. A lingering question into the matter might involve the
idea that the proposed solution would not work for every
person, every time. By that I mean healthcare cannot remedy
every problem faced by each individual, thus prompting the
belief that the recommendation is not good enough. I would
talk about these doubts to my family, who could use their
outside knowledge on problem solving and the public affairs
prompting the investigation to assure me that no solution to
such a complex issue will ever be 100% effective. This would
be an effective method of considering ethical questions for me
because it would help vocalize and sort out my thoughts in a
comfortable, relaxed manner.
On a less black and white matter, engineers may need to
go beyond the codes of ethics to determine the correct path to
take on ethical issues. For example, had the government
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Engineering Code of Ethics, which like the NSPE’s code,
summarizes principles and canons that engineers must uphold
[8]. The first Fundamental Principle listed states that
engineers should use “their knowledge and skill for the
enhancement of human welfare” [8]. This is not helpful for
the given situation because while it is the principle that relates
the closest to protecting human interests, it does not address
how far engineers should extend themselves to protect those
rights. It can, however, be concluded that engineers must
stand up for human interests, yet it does not describe whether
they must police the operation of their developments. To
better answer this question, I would turn again to another
personal source of advice, this time a church. A religious
advisor would help me make ethical decisions because he or
she is someone that has knowledge on a topic that is important
to me: my faith. In addition to legal obligations, I try to base
my actions off of religious codes, which is why I would look
to someone with a great deal of insight on that matter. I would
consult this person on the matter of what should be done about
potential misuses of my recommendation. I would allow this
person to give me advice because although the codes do not
give any direction or suggestion that measures need to be
taken, my own moral compass would suggest that I should
have some responsibility in ensuring the SEIPS model is used
as it was intended. If, for example, the religious leader
suggests that I take actions to ensure that all people are treated
fairly, I am still faced with the conflict of whether to take
those actions to protect peoples’ best interests or to allow the
government to enforce and monitor the process.
While still struggling on the issue of how to react to
potential misuse of my recommended SEIPS model to
alleviate high healthcare costs and patient safety concerns, I
would seek other sources of advice until a decision can be
made. This final source would be an article encompassing the
engineer’s role in engineering ethics, titled “Engineering
Ethics Beyond Engineer’s Ethics” [9]. In the article, authors
Josep M. Basart and Montse Serra claim that engineering
ethics extends further than the individual engineer. They
state, “Engineers are not a singularity inside engineering; they
exist and operate as a part of a complex network of mutual
relationships between many other people, organizations, and
groups” [9]. This suggests that engineers are not the sole
people responsible for engineering issues; other groups
including management and clients play a role too. In the case
of engineering healthcare, the government plays a large part
because they ultimately make decisions regarding the
recommendation made by the team and will continue to be the
group mainly responsible for its progression and continuation.
This source is helpful both because of its specificity and
generality. It is specific because it addresses the complex
issue at hand, which is the issue of who claims responsibility
for guaranteeing that all parts of the process are done
appropriately. However, the generality of the article, which
is evident because it can be applied to various situations, not
specifically healthcare, is helpful as a guide to numerous
ethical cases. As a result, it can be consulted for various
directions been to cut costs in order to balance the budget,
engineers may have solved the problem of high costs at the
expense of quality. In this case, the engineers could have
fulfilled many duties described in the NSPE Code of Ethics
such as acting as a “faithful agent or trustee” to an employer
and “objective and truthful in professional reports”. These
duties would have been met simply by being honest and
obedient. However, not all parties, namely the patients,
would be treated fairly. When a problem like this arises, I
would consult other sources outside of the codes of ethics.
One such source may be an article discussing ethics in
healthcare, which is more specific to the issue at hand. In
“Preventing ethics conflicts and improving healthcare quality
through system redesign”, the authors of the article describe a
scenario in which doctors withhold information from a
patient, and as a result, quality and ethical considerations are
diminished [7]. In this case, that situation highlights how
quality and ethics in the healthcare field are closely related.
As an engineer who was directed to cut costs in healthcare, I
would look at that situation and use its message to stand up
for the patient because when the patient’s interests are not
met, the integrity of the hospital or healthcare network is
compromised. As a result, the patient loses because the
quality of care is poor, and the hospital (and consequently the
government for ordering the cost cuts) loses because its
professionalism is undermined. It would be my responsibility
not only because it helps society, but also because it would
benefit the company (or government) as well. While not
exactly related to the current situation, articles like this can
apply to the matter at hand in a way that guides the engineer
to make an ethical decision. In addition, relevant articles may
be better at making ethical decisions than engineering codes
and canons because they describe more specific situations,
can reflect on outcomes of related issues, and provide clear
messages about what should be learned from mistakes.
The second ethical dilemma might occur when thinking
about the practicality of the solution. The team and I have
already deemed the recommendation ethical, yet how it is put
into practice may reveal new moral questions. For example,
because the SEIPS model is not an explicit set of instructions,
it will be difficult to monitor how specific health networks
employ it. A negative situation might arise if a group or
individual uses our recommendation to harm other parties.
This may occur if a hospital decides to integrate the different
departments by using the same nurses everywhere. While
costs may be reduced and individual nurse productivity
increased, patients may feel a negative effect if they receive
less individualized attention. Thus the question arises: do we,
as the engineers responsible for the recommendation, have a
duty to ensure that it is executed in the intended way? To
answer this, I would again look to an engineering code of
ethics because it was created to assist engineers in reflecting
on their projects. While it may not always prove useful, it is
important to consult these codes to consider the same things
that others in the same situation may be considering. For this
example, I would consult the Institute of Industrial Engineers’
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situations to further allow engineers to develop with
professional integrity.
[9] J. Basart, M. Serra. (2011). “Engineering Ethics Beyond
Engineers’ Ethics.” Springer Science+Business Media. (Print
article). Vol. 19. Pp. 179-187
CONCLUSION: RECOGNIZING VALUE IN
ETHICAL RESOURCES
ACKNOWLEDGMENTS
I would like to thank numerous people who helped me
through the process of writing this paper. First, I would like
to thank Dr. Bursic, my ENGR11 professor, for making me
feel comfortable with the engineering curriculum despite
coming into class without much experience. I would also like
to thank the librarians at the Bevier Engineering Library for
guiding me through documenting my sources and the Writing
Center for assisting me through the writing stages. Finally, I
would like to thank my Writing Instructor, Ms. Faina, for
patiently answering all of our questions throughout the
progression of the paper.
As individuals and a team, the group decides move ahead
with the process by giving the final recommendation to the
governing body. We have decided that our plan is in line with
the NSPE’s code to promote societal wellbeing and that
monitoring the proper implementation of the recommendation
is the role of engineering in its entirety, meaning engineers
and all those responsible. Therefore, engineers should work
together with the government over time to ensure that the
intended consequences of the SEIPS model are met. Finally,
the team reflects on the process of reaching this conclusion.
Multiple sources were used to assess the ethical matters in
question, and while some were appropriate for situations
better than others, the combination of those sources, whether
traditional or unconventional, is the best method for assessing
issues in an ethically charged scenario.
REFERENCES
[1] C. Carayon. (2012). “Emerging role of human factors and
ergonomics in healthcare delivery-A new field of application
and influence for the IEA.” (Book). DOI: 10.3233/WOR2012-0096-5037. Pp. 5037-5040
[2] W.B. Rouse, D. A. Cortese. (2010). “Introduction.”
Engineering the System of Healthcare Delivery. (Book). DOI:
10.3233/978-1-60750-533-4-3. pp. 3-14
[3] “Total Expenditure on Health.” (2012). Organization for
Economic Co-Operation and Development. (Chart).
http://www.oecd-ilibrary.org/social-issues-migrationhealth/total-expenditure-on-health_20758480-table1
[4] P. Carayon, A. Hundt, B.T. Karsh, et al. “Work system
design for patient safety: the SEIPS model.” Quality and
Safety
in
Healthcare.
(Online
article).
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2464868/?to
ol=pmcentrez&rendertype=abstract
[5] W. Hwang, J. Chang, M. LaClair, et al. (2013). “Effects
of Integrated Delivery System on Cost and Quality.” The
American Journal of Managed Care. (Print article). Vol. 19,
no 5. pp. e175-e184
[6] “Code of Ethics for Engineers.” National Society of
Professional Engineers. (2007). (Online publication).
http://www.nspe.org/Ethics/CodeofEthics/index.html
[7] W. Nelson, P. Gardent, E. Shulman, et al. (2010).
“Preventing ethics conflicts and improving healthcare quality
through system redesign”. BMJ Quality & Safety. (Book).
DOI: 10.1136/qshc.2009.038943. Pp. 526-530
[8] “Engineering Code of Ethics.” Institute of Industrial
Engineers.
(2013).
(Online
publication).
http://www.iienet2.org/Details.aspx?id=299
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