Ethics Toolbox: From Toothless Barking to Problem Solving
March / April 2005
Ethics Toolbox
From Toothless Barking to Problem Solving
While we all purport to value ethics, the real value of ethics is unclear to many. Few perceive ethics as a valuable problem-solving resource. Yet, while ethics is touted as among the most serious and important of issues, it has good bark but little bite. Despite its increasing appearance in the context of healthcare discussions, it is often little more than a platitudinous, intellectual exercise. As Descartes reminded us, we are thinking beings, and ethics makes us stop and think. Ethics, however, is only that, for it lacks the sanctions or teeth of a rule of law. While it may have some influence in shaping what we do, it rarely forces us to rapidly and decisively change direction or improve our desired outcome. If we truly value the role of ethics in decision-making, we need to guard against it being undermined or diminished.
Too often, when an ethical issue poses a hard choice and lingers in your gut, its complexity and impact is acknowledged, articulated, and vaulted into the loftiest heights of mental speculation where it hovers out of reach and touch. That’s unfortunate; hard choices mandate careful attention, consideration, decisiveness, and action. Yet, despite good intentions and well-meaning motivations, we are tempted to accept resolution much too easily and are satisfied with the opportunity to toothlessly gum the fodder of these issues and let them evaporate rather than resolve them.
When faced with a hard choice, we don’t bring out the ethical toolbox to figure out the most appropriate or effective way to address the ethical dimensions of a given problem. In fact, more often than not we assiduously avoid them. We find mechanisms to ignore rather than address. And who do you call to address these issues? Ghostbusters? 1-800-ethicist? How do you even find one? How do you know if you are getting a good one?
If an issue is perceived as truly serious, most of us will call a lawyer. If it’s that bad, perhaps “there oughta be a law.” Even the “turf” of the ethicists is up for grabs. Often, the interlopers are lawyers who are not reluctant to take on this role despite the paucity of ethical problem-solving skills in their curricula, experience, or training. Despite those shortcomings, they wing it and are willing to try to resolve most any complex ethical issue. Perhaps deep down we all believe that we have the innate capacity to address the most difficult ethical issues and dilemmas and that we are endowed by the creator with sufficient talent and tools to affect this with ease and grace. If we really value ethics, we should give it the attention and expertise it deserves.
Ethics Into Action
My analysis thus far may be exaggerated, hyperbolical, and unfair, even if it suffers from coarse grains of subtle truths. Perhaps ethics is indeed a powerful tool that can be effectively employed in such a way that can yield more thoughtful analyses, assessment, and choices. If that is the case, can we move from toothless gumming to greater tenacity and value in the manner in which we address and impact these important issues?
The ancient Greeks realized the importance of the integration of knowledge and ethics. Hippocrates in his famed oath speaks of how we should differentially assess alternatives to arrive at the most reasonable course of action. Acting with “evidence-based” practices has long-established roots. If it’s worth doing, then it’s worth doing well, in ethics, medicine, or anything else. Ethics is most credible and valuable when it is used as a tool for defining and solving problems rather than merely as an exercise for sharpening our wits. We must take a more rigorous posture and move from dabbling in ethics as if it were a hobby to treating it as a more defined discipline.
If, as many thought leaders across the healthcare continuum suggest, many of today’s issues and debates are infused with ethical issues, then we must deal with them proactively rather than by the seat of the pants or in tourniquet fashion. Genomic medicine, predictive modeling, pay for performance (P4P), high-cost biotechnology drugs, and consumer- and purchaser-driven healthcare are full of ethical questions that we must integrate into our thinking and policies. We must get it right. When ethics can help identify and justify better courses of action — by assessing an array of the best alternatives or by employing pivotal principles — it should be employed.
Just as we have elevated the level of discourse with the infusion of evidence-based medical criteria, so too must we elevate the level of ethical discourse. Using ethical guidance (not just compliance masquerading as ethics) to help create the architecture for appropriate reimbursement, in which patients and providers can be more comfortably and fairly accommodated, will require roadmaps and examples to help guide us as we expand the fringes of thinking and practice. At the same time, we must remain cognizant of the distinctive ethical implications of our initiatives and ensure fairness, continuity, and consistency. Rethinking benefit design, including definitions of benefits, limitations, coverage caps, and expectations, as well as the concept that the patient will share in the responsibility for care within an ethical framework, will also be explored. This must occur for us to begin to answer such questions as how much healthcare we are entitled to and whether such entitlement pivots on financial limitations. This also raises the question, to what extent, if any, should people be personally responsible and financially accountable for their own genetic predisposition? These preliminary concerns must be attended to before we can address the more targeted questions of how we should resolve economic tensions when drug costs can exceed thousands of dollars per day or when specialty medications and technology are clearly lifesaving, and the patient has exhausted less costly conventional options. What is the responsibility of the payer and purchaser for meeting those needs? Even conventional concepts such as co-pays, which were initially intended to serve as mechanisms to reduce overuse or address moral hazard issues, are becoming potential barriers to needed care. This, too, will raise ethical implications of benefit design and perhaps restructuring the benefit to deal with the risk. This is not just an accounting or actuarial exercise. Tradeoffs, fairness, and the very underpinnings of what insurance is and should do are at stake. A radical re-thinking rather than a mere facile balancing of competing alternatives or goal may be necessary. The process of understanding how we can best explore issues so that we can more effectively resolve problems is in order. As we explore these issues in the context of this column, thought leaders will share their perspectives and expertise with me to explore the distinctiveness of these issues and offer helpful recommendations to help resolve them.
We need to move beyond the vagaries of ethereal pronouncement to reflective resolution. As we pursue a course of discipline, rigor, and careful deliberation, we will require a firm foundation upon which to build our knowledge base for our deliberations. It is my intention that this column be a forum for that kind of commitment and responsibility.
By scanning the ethical terrain, we can identify the best paths to pursue to reach desired outcomes while avoiding perils and pitfalls along the way. We can better focus on what needs to be highlighted, protected, and preserved. Ethical problem solving can help us expand the horizon and breadth of our thinking as well as sharpen our abilities to define and solve problems and dilemmas.
Dennis Robbins (DennisRobbins@cox.net) is a healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS) and co-founder of the Policy Group. Robbins has worked extensivelyÝon the interface of ethics with quality, liability, payment systems, health law, and health policy. He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, and government. He is respected for his extensive work on ethics and payment systems and was honored by Managed Healthcare Executive Magazine as among the top 10 “keenest thinkers” in managed care. Robbins was a National Fund for Medical Education Fellow in the Kennedy Interfaculty Program at Harvard, where he was a visiting scholar and research fellow in ethics in the Division of Health Law and Policy. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard.