Fairfield Now - Summer 2008
The Ethics of Healthcare
The Fairfield University community weighs in
By Nina Riccio
The topic of universal healthcare is of concern to us all and has been a major focus of this presidential campaign. Looking at healthcare as a basic right for all Americans is not just a program change; it represents a major shift in the way we think about employer and governmental responsibilities, and forces us to consider our obligations, if any, to each other. Fairfield Now has asked three members of the Fairfield community - all with very different areas of expertise - for their thoughts on this issue.
Joseph Pachman, M.D., M.P.H., MBA '01
Formerly Chief of Occupational Medicine, Norwalk Hospital
Joseph Pachman, M.D., M.P.H., MBA '01
We currently have a system whereby people without insurance attempt to make do when they have a medical problem. In an emergency room, it's not unusual to see someone try to claim an injury through workman's compensation, for example. Doctors and providers often support this because they want to see that person treated, but it creates a burden on business. Right now, there is a lot of this type of cost-shifting happening because people don't have adequate insurance to pay for what they need.
Another serious problem is that people without coverage tend to use the emergency room as their primary care providers. This is not only inefficient, it's overly expensive and it clogs the system so that the emergency room can't function as it should. A single payer system (i.e., a system whereby one entity, in this case, the government, pays the bills) would not only eliminate paperwork and cover more people, it would be less cumbersome than the system we have now. And with a single payer system, those who wish may purchase additional health insurance if they want greater options and flexibility.
It's human nature that we don't treat healthcare as we do other things - we don't comparison shop, and we tend to believe that the more technology we use, the better. The current system has incentives in place for more procedures, more tests, more technology. It rockets out of control. For example, in the last 10 years there have been significantly more fusion surgeries for problems that used to be treated more simply, but we haven't necessarily had better outcomes.
We're one of the few industrialized nations in the world without universal healthcare, and we need to face the reality that we need it. Our rates of infant mortality are higher than just about any country in Western Europe, and our life expectancy is lower. We have more surgeries and procedures, but not necessarily a better quality of life.
A national healthcare plan means reallocating resources in a better fashion. I believe it would also encourage better focus on primary care, resulting in more physicians choosing to go into primary care once we change the whole incentive and distribution system. There would be less use of the emergency room and fewer unnecessary tests and surgeries. Of course, for the system to work we need good gatekeepers. Those who have incentives to keep doing procedures shouldn't be the ones making the decisions. For example, a long-running federal investigation into the orthopedic device industry's kickback payments to hip and knee surgeons has focused attention on the "demand issue" in healthcare. The government has focused on the money many doctors receive as the companies' paid consultants. As recently charged, once surgical device companies develop a product, leading doctors are hired as consultants who are later used to train other doctors. The alarming result is higher costs to unsuspecting consumers in the unmanaged healthcare system. Sadly, this is just one of many examples of the multitude of problems in our overly expensive, inefficient, and often ineffective healthcare system. Is it worth the price of not having to wait for an elective procedure?
Mary Ann Christopher '79, MSN
President and Chief Executive Officer, Visiting Nurse Association of Central New Jersey Health Group
Mary Ann Christopher '79, center, discusses the benefits of immunization with a mother prior to her
child's vaccination by an advance practice nurse.
To be truly effective, changes to our healthcare system must be fundamental, realigning our focus from acute care toward greater support for a range of treatment options and settings, such as neighborhood clinics, hospice, and at-home care. Such a plan will likely involve a mandated insurance program with a sliding scale subsidy.
We must develop a system whereby care is delivered in the most appropriate setting. Recently, for example, I worked with a woman who had terminal cancer; she wanted to be treated and ultimately to die at home, surrounded by her husband and three young children. Yet her inadequate health coverage did not support this - it would only reimburse care delivered in the hospital. Discharge to her home was only possible through philanthropic support. Much of the problem rests in the fact that the system is archaic, developed for a time before higher and more varied levels of care were possible in other settings.
Millions of dollars could be saved if we were more vigilant about patient safety. Every day, there are 44,000 preventable incidents of harm with nearly 100,000 deaths annually. We need to implement practices that we know reduce adverse conditions such as ventilator-associated pneumonia, pressure ulcers, and antimicrobial resistance.
Investing in technology is another way to cut costs while delivering better care. We have a 92-year-old patient with congestive heart failure who had previously been admitted to the hospital 12 times in four years. Last year, by frequently monitoring him at home instead of waiting until he had a problem, he got through the year without a single hospital admission. We now have scales, blood pressure monitors, and other equipment that can be set up in a home and connected electronically to a central system; the patient can use the equipment, and a healthcare provider can take action based on information that he or she receives on a daily basis. As it stands now, chronic disease intervention accounts for 80 percent of all healthcare dollars spent; yet our current system is primarily focused on acute interventions.
A commitment to prevention is equally key to any reform effort. For every dollar spent on childhood immunizations, $6-$30 is saved in the prevention of illness. Yet only 81 percent of American children are age-appropriately immunized. Adult rates of immunizations for influenza and pneumonia are even more dismal; they're administered at only 56-70 percent of the desired rate.
Right now, there are many things working against delivering good preventive care. If we reformed malpractice laws, we'd go a long way toward encouraging physicians to go into primary care. Forgiving education loans - particularly for doctors, nurses and other clinicians willing to work in underserved areas - would also help. We can address the nursing shortage, which threatens to create a vacancy rate of 43 percent by the year 2020, through a private/public funding partnership. Finally, laws in each state must allow for the fullest expansion of the nursing role; in many states, they are restricted as to what they can do. Using nurse practitioners in neighborhood-based sites such as health centers, schools, and senior centers allows patients greater access and results in a sharp reduction in emergency room care. As an example, a study of 2,700 at-risk children who regularly saw a school-based nurse practitioner found that none sought the emergency room for primary care needs. The same study also showed that 35,000 hours of parental and childhood absenteeism were avoided - children didn't miss school, and parents didn't miss work, because the nurse practitioner was able to treat asthma, upper respiratory infections, etc. right at school.
There are no easy solutions to the growing gap between quality affordable healthcare and those who need it. Comprehensive reform must be transformational if it is going to allow us to open the door to healthcare for everyone in our country.
Rev. Francis Hannafey, S.J.
Chair and Associate Professor, Religious Studies Department
Frank Hannafey, S.J., has taught religious studies and ethics at Fairfield since 1998; he is particularly interested in business ethics.
In recent years, there has been a lot of discussion about whether access to healthcare is a basic human right. This is a radically new and somewhat controversial way of thinking, because to call something a basic human right is to infer that other humans have an obligation to fulfill that right.
From a Catholic point of view, the human being has God-given dignity. The question then becomes, what obligations do we have to preserve that dignity? Pope John Paul II wrote beautifully about the moral obligation to honor and preserve human life; that life is a sacred gift from God, and we hold our bodies in stewardship. It's difficult to honor God and fulfill our duties to each other if we're in continued pain and ill health. Access to healthcare for all those who need it, regardless of ability to pay, might be inspired by the moral principle of distributive justice, which is part of Catholic social teaching.
The way Jesus cared for the sick and vulnerable was an inspiring model of our religious and moral obligation to each other. As it is now, there are tremendous problems with the increased cost of healthcare, and places like universities and other non-profits get hammered. Many economic problems can be solved if we reform this system. After all, if we are a healthier society, we'll be a more productive, effective society. I wonder if the way our system is designed can at times shift the focus and de-personalize care. With our focus on acute care and technology, for example, do we in some clinical situations forget the person and family in how care is delivered? Can a person be instrumentalized because of technology?
If we decide as a society that access to care is a basic human right, we need to face the next question: What is basic medical care? There is a 500-year-old Catholic tradition that examines the distinction between ordinary, or proportionate, care and extraordinary, or disproportionate, care. Medical care that is deemed "ordinary" assumes that there is a moral obligation to meet that need. Care that is deemed "extraordinary" is considered morally optional. So, is quadruple bypass surgery for an 88-year-old ordinary care? Today, it may well be. It depends on the situation of the patient and on the available technology. What is deemed extraordinary today might be ordinary a few years from now.
It's been said that the moral character of a society can be judged by how that society cares for its most vulnerable - the sick, the elderly, the children, the impaired. The issue of universal healthcare is one that allows us a chance to judge ourselves as a society and to assess our priorities as a nation.