Ethics Toolbox: Healthcare Cost and Quality
September / October 2006
Ethics Toolbox
Healthcare Cost and Quality
Cost considerations are now so integral to our healthcare debates that their absence might make us feel as if something important were missing. Despite the intensity of these discussions, there have been few effective solutions to control or reduce healthcare expenditures. Issues underlying the “cost question” — rights, duties, and responsibilities — are often glossed over as we search for the antidote to our financial woes. We seek low cost with high quality, yet our medical practices often seem to shortchange quality. In fact, some of the challenges we face today have evolved from our reluctance to acknowledge cost as a significant determinant in patient care choices.
Cost considerations are now so integral to our healthcare debates that their absence might make us feel as if something important were missing. Despite the intensity of these discussions, there have been few effective solutions to control or reduce healthcare expenditures. Issues underlying the “cost question” — rights, duties, and responsibilities — are often glossed over as we search for the antidote to our financial woes. We seek low cost with high quality, yet our medical practices often seem to shortchange quality. In fact, some of the challenges we face today have evolved from our reluctance to acknowledge cost as a significant determinant in patient care choices.
Society and employers demand that we develop more effective models for integrating the clinical with the financial. Certainly, there is nothing endemic to clinical care that makes it intrinsically inefficient nor is there something endemic to financial efficiency that makes its inappropriate for the clinical forum.
More than 30 years ago, a prominent physician, Robert Sade, contentiously argued that healthcare is a commodity with which the physician ought to be able to do as he chooses. He believed that in a free and unfettered society, one must have the freedom to “sustain his own life by producing economic values in the form of goods and services…to exchange with other(s)… who are similarly free to trade…or not. (as cited in Reiser, Dyck, & Curran, 1977, p. 574)” According to Sade, medical care is not a right. In fact, the very concept of medical care as a right is immoral according to Sade because it compromised the basic rights of physicians — the right to one’s own life and having the freedom to support or maintain it as he best sees fit. Sade argued that medical care should not be spoken of in the context of rights, privileges, or desserts; instead it is a “service provided by doctors and others to people who wish to purchase it. (Reiser, Dyck, & Curran, 1997, p. 574)” This is analogous to the baker who bakes his bread and sells it to those who can afford to purchase it. The baker should be able to choose how and to whom he disposes his goods and services.
However, healthcare is not bread! Healthcare is not a straightforward marketing of services, nor is it simply a good or service to be sold on demand to a purchaser. It is a more fundamental need associated with the common good, public safety, and general public interest. When goods or services are provided, and one is compensated for such goods and services such that a profit is generated, it suggests a business operation. But, healthcare is arguably unlike any other business. While food, clothing, and shelter are human needs, they do not purport the same societal and professional commitments as healthcare. It is not merely a question of protection and safety as it is for the bridge builder, the engineer, the pilot, and the air traffic controller. It is the very intimacy of the provision of medical care that constitutes the difference. Patients allow healthcare providers to do to them what under no other circumstances would be allowed. Without their consent, caregivers’ actions would be heavily sanctioned in polite society and in our court system. Caregivers are in the “business” of cutting into people, invading their internal structures, resecting pieces of their being, modifying the physiognomy,and the like.
We must enlist our creative energies to address and solve these issues, not avoid them. The challenge of integrating legitimate costs with quality lies at the heart of our health, welfare, and common good. With vision, integrity, and hard work, perhaps we can have our bread and eat it, too.
Dennis Robbins is a healthcare innovator, author, and thought leader. He is president of Integrated Decisions, Ethics, Alternatives, and Solutions (IDEAS). He has served as an advisor on ethics and related issues for major national organizations, associations, law firms, hospital systems, private industry, and government. Robbins holds a PhD in philosophy from Boston College and a postdoctoral master’s degree in public health from Harvard. He is a member of the Editorial Advisory Board for Patient Safety and Quality Healthcare and member of several technical and scientific advisory boards. Robbins is also an adjunct professor at the W.P. Carey School of Business at Arizona State University, where he teaches graduate courses in ethics and health law. Robbins may be contacted at Dennis.Robbins@cox.net
References
Reiser, S. J., Dyck, A. J., & Curran, W. J. (Eds.). (1977). Ethics in medicine. Cambridge, MA: MIT Press.