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Ethics committees and cost containment.

Health care institutions are under strong pressures to contain costs. Should ethics committees within those institutions assist in such efforts? If not, can ethics and economics be separated that neatly? The complexity of this issue derives in part from the large array of cost containment activities available to health care institutions.

In a broad sense, all institutional efforts to deliver services more efficiently can be understood as cost containment efforts, from changing to lower cost suppliers of linens or medications to streamlining billing procedures. However, decisions to adopt such measures would normally have no direct or significant impact on patient care and are more appropriately wed as managerial, rather than strictly ethical decisions. Consequently, they would not be brought to the attention of an ethics committee.

But the line between management decisions and those that are strictly ethical is often not clear. For example, managerial and ethical issues are intertwined when a decision is made to reduce nursing staff coverage in an ICU, for this could well have a significant adverse impact on patient care. It is the potential for affecting patient care that gives management decisions an ethical impact and that might make those decisions a proper concern of an ethics committee.

Even though restricted in this way, a wide range of cost containment practices and policies with implications for patient care remains. What are some examples? A hospital may seek to develop means for speeding the discharge of Medicare patients for whom it receives a fixed reimbursement under the DRG system. Or it may develop a policy to deal with patients who have overstayed their welcome by remaining beyond the number of days for which Medicare will reimburse the hospital. Whether to expand a consistently overburdened ICU is an institutional capital expenditure planning decision fraught with life or death consequences for future patients. Moreover, a policy setting standards for admission of individual patients to the ICU will have a direct impact on identifiable patients accepted or refused admission under that policy. Whether to close money-losing emergency departments or clinics that largely serve indigent or Medicaid patients are policy decisions that will seriously affect the access of such patients to health care. These are all decisions that affect patient care and raise serious ethical concerns. Yet ethics committees usually lack decision-making authority in any of these matters and typically play a limited advisory role at others' request. Moreover, it would be highly unusual for hospital management to involve an ethics committee in most of these policy and planning decisions. What then are the arguments for ethics committee involvement in cost containment decisions-, The fundamental point in support of involvement is that many policy decisions have significant ethical implications and therefore seem within the mandate of ethics committees. An ethics committee may sometimes reasonably believe that it will be the most effective, or even the only, spokesperson for patient interests and for the ethical responsibilities of the institution in such decisions. If the ethical aspects of these cost containment decisions are to receive due consideration, it is sometimes the ethics committee that must press diem.

Further, an important factor affecting the ethical acceptability of most cost containment measures is the process by which those measures are adopted-that process should be public, allowing input from all affected parties so as to increase policymakers' accountability for their decisions. Consideration by the ethics committee can help ensure that difficult and controversial ethical issues raised by some cost containment efforts are more fully and publicly aired, thereby increasing the overall legitimacy of the decision process.

Finally, the ethics committee may reasonably expect that its involvement in cost containment decisions will result at least in some instances, in ethically sounder decisions and policies. What are the arguments against ethics committee involvement? Consider first cases in which the institution's management (or another institutional committee with policymaking authority) brings a cost containment program under consideration to the ethics committee for its input and advice. If management does this because it is seeking an ethical evaluation of a cost containment measure, most of the reasons that support the ethics committee's involvement will apply. But the motivations of managers seeking consultation sometimes may be quite different. Perhaps die most important argument against ethics committees accepting invitations to become involved in cost containment efforts is that management of health care institutions may seek to use these committees to put an "ethical seal of approval" on such efforts, even in cases where no such approval is warranted.

The danger of being co-opted by institutional interests, of being asked to reign in uncontrolled costs in order to promote the institution's financial well-being, is a serious threat to the integrity of the ethics committee. like judges, who must avoid not only actual conflicts of interest, but even the appearance of conflicts of interest, ethics committees must be, and must be perceived to be, fully independent bodies. They should be beholden to no particular group or interest.

Serious cost containment efforts will often involve conflicts of interest in which the institution's financial welfare must be weighed against preserving high quality patient care. In such cases, ethics committees must take care to preserve their most important asset-their reputation in the institution for independence and integrity in counseling on ethical issues. A second argument against ethics committee involvement concerns the unrepresentative nature of the cost containment policies that are likely to be brought to the ethics committee. When an institution's management is under powerful pressure to control costs, it is not likely to bring cost containment measures to an ethics committee if it expects the body to raise serious objections to those measures. But these are precisely the instances in which the committee's perspective may be most needed. Selective consideration of only less controversial cost containment measures may no% on balance, be desirable for the ethics committee or beneficial to patients or the institution. If the committee consistently waits to be asked to review policies, it may be precluded from considering ethically more controversial measures to which management anticipates it would lodge serious objection. With no regular practice of broad involvement in cost containment policymaking, which policies even come to the committee's attention will often be left to chance. If the committee has been involved with similar policy issues within the institution, its silence in the cases of which it is unaware may mistakenly be interpreted as approval or at least lack of objection. Yet, if the committee has not been invited to participate in the decision-making process in a particular instance, it is unlikely to have all relevant information or ready access to the locus of decision-making authority on the matter. This may leave it with little choice but to issue uninvited ethical broadsides critical of institutional policy, a practice likely seriously to impair its effectiveness or even to threaten its very existence.

The fundamental conflict that ethics committees face when they consider whether to become involved in institutional cost containment efforts is that on the one hand, they may rightly perceive themselves as an important advocate of patients' interests when decisions about pursuing particular cost containment measures are made. They may lightly believe that ethically better decisions will result from their participation. On the other hand, they may risk being coopted in the service of the institution's financial interests should they participate in these decisions. Their reputation for independence and integrity, as well as their general effectiveness in carrying out their broader mandate within the institution, may be undermined by such participation.

It would be neither defensible nor feasible for ethics committees to adopt a general policy of avoiding involvement in cost containment decisions to avoid such difficulties, however. The cost would be too great in a few important instances. Yet if ethics committees consider all policy decisions involving cost containment issues, they risk undermining their effectiveness. Consequently, ethics committees must be selective in participating in cost containment decisions to balance the important good they can do for patient care in some instances against the threat to their integrity, reputation, and very existence that such participation could entail. They should approach cost containment issues and programs with care, weighing in each case the expected benefits and risks of their involvement to all affected.
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Title Annotation:health care institutions
Author:Brock, Dan W.
Publication:The Hastings Center Report
Date:Mar 1, 1990
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