Nonmaleficence and Healthcare Cost - Dissertation Example

Nonmaleficence and Healthcare Cost Introduction Various ethical principles apply to the health care practice. Four of these are the basic ethical principles which health care practitioners apply to their practice. These ethical principles include: autonomy or self-determination, beneficence, nonmaleficence, and justice. The principle of self-determination basically sets forth that a patient has the right to make an informed decision about his care. His decisions must therefore be respected by health professionals. The principle of beneficence is basically about acting for the benefit of the patient – that all actions are geared towards ensuring one’s actions would be for the good of the patient. This principle is very much related to that of nonmaleficence which basically mandates that no harm must not intentionally or non-intentionally be visited upon the patient by the health professional’s actions. Finally, the principle of justice is about giving a person his due and what he is entitled to. These principles form the foundation of all health care decisions. For health professionals making decisions about a patient’s care, these principles help guide the healthcare practice towards morally and ethically prudent decisions. In the current era of economic recession which is also causing multiple budget cuts, the imposed health budget cuts seem to be coming under scrutiny for their negative implications to the delivery of health services. The principle of nonmaleficence is being considered as a primary consideration in scrutinizing the imposition of health care budget cuts. In effect, the application of health budget cuts contradicts the principle of non-maleficence. This paper shall consider such thesis, discussing both sides of the statement in the hope of eventually establishing a scholarly and comprehensive understanding and resolution of the issue. Discussion Since the beginning of the economic recession period, government spending in almost all sectors of social service has taken on budget cut considerations. These budget cuts have reduced funding for some health care services, and in some areas of health service, have led to total elimination of monetary support. Forms of rationing and rationalization in health care spending have also been implemented. These forms of budget cuts and limitations however have resulted to sacrifices in health care spending – some of these sacrifices have impacted on the quality and quantity of care made available to the general population. In considering the principle of nonmaleficence and its application to the reduction of health care spending, two sides of this issue are apparent. In one side, nonmaleficence clearly portrays how budget cuts cause both direct and indirect harm to patients. On the other side, it may be argued that these budget cuts do not cause the patient much harm; instead they make the redistribution of limited resources possible. The discussion below shall review both sides of this issue. Budget cuts cause direct and indirect harm to patients Budget cuts cause both direct and indirect harm to patients. Health care leaders point out that health budget cuts potentially endanger patients (Grant, 2011). With higher health premiums, higher co-pays, as well as deductibles, more people seem to be doing away with preventive care. Patients entering hospitals seem to sicker and harder to care for because they often wait for the last possible moment to seek medical care. By the time they seek medical care, their illness has already progressed into less manageable stages of care (Grant, 2011). Imposing budget cuts in the health care practice have also come to mean less nurses hired to care for patients. In effect, fewer nurses are available to care for patients who are hardly reduced in number (Grant, 2011). In considering budgets, numbers are always involved. For those who control the budget, numbers often rule their mind and their decisions. In health care, applying such mindset is not always the best policy (George, 2011). People are after all at the very end of such budget considerations. Budget cuts imply more than numbers, they may mean that a 6 year old girl is not getting a new kidney, or that newer and less experienced nurses have to be hired to care for ICU patients. In an article by George (2011), he sets forth that in the Manchester Community Health Center (MCHC) the community being served is a very vulnerable community. About 45% of their patients are uninsured, 45% are on Medicaid, and such vulnerable population is largely composed of women and children (George, 2011). A great majority of the patients do not speak English, hence about 1 in 2 of these patients need the services of an interpreter. There is a challenge of helping the health care workers get up to date with the changes in health care, including the demands of their diverse population (George, 2011). The proposed 46% budget cut for community health center allocations is a very unfortunate decision. This percentage would significantly impact on the people and the community at large. These budget cuts would increase waiting times in the community health center from three weeks to about six months (George, 2011). Even with these budget cuts being made, the center is still seeing an increase in people seeking its services. The current tough economy has not reduced the influx of people seeking health services in the community health center, in fact such influx has even increased. The center has also experienced more setbacks with Medicaid ceasing their payments of their prenatal chart review (George, 2011). The center’s operating budget for a year does not even exceed 5 million dollars. These considerations pose difficulties for the center in general. With the budget cuts, the center would reduce its budget by about 200,000 dollars. These budget cuts which are shown to significantly affect the MCHC impact negatively on the community being served; however, this trend is not just apparent in MCHC, it is a repeated trend in other parts of the country where the 4.5 million dollar reduction of funding to community health centers is being carried out (George, 2011). These budget cuts would very likely impact negatively on these community centers, causing the layoffs of employees and even the closures of some of these centers. These budget cuts may just translate to numbers taken out or included in a piece of paper, however, in the community centers like MCHC, these budget cuts mean that some programs would have to be removed (George, 2011). These programs include perinatal care coordination, diabetic education, breast cervical cancer prevention, and nutrition. These programs are considered one-person programs with one person usually running such program. Budget cuts may mean the dismissal of such a person, and the elimination of the services and programs he/she runs in the center. These programs are actually crucial in the prevention of different diseases (George, 2011). Hence, such budget cuts will strain the use of hospital emergency rooms for nonemergency care because those who are released from the program would have to seek alternative channels of care (George, 2011). Advances in the field of health care gained through years of financial allocations for health care may be lost. In an Australian study, it is claimed that medical research has been responsible for the increase in life longevity gain of 8 years worth an estimate of $2.9 trillion alongside gains in quality of life worth $2.5 trillion in avoided health expenditure (Jennings, et.al., 2011). However, with health budget cuts being implemented, these advances would now potentially be undermined. These reductions have dangerously placed patients under potential chronic care away from acute care settings and on to community care settings. The breakthroughs and evidence-based solutions are essential at this point of medical care. A reduction in the annual health budget will not just impact on the current generation, but on future generations as well (Jennings, et.al., 2011). Health research is an important aspect of health service delivery and reform. Much of Australian health and medical research is based on disease prevention, improved clinical care, and new therapies and vaccines which are features of health care which can potentially reduce future health expenses. “Indeed without such research, the impact of health reform on patient-relevant outcomes such as death and disability will remain substantially uncertain” (Jennings, et.al., 2011, p. 1). Health budget cuts bring harm to patients and to health care in general because health research and innovations potentially assist in addressing unique health issues among the vulnerable indigenous population. This can be seen in the case of the ‘polypill’ which is a low cost and once a day pill for the prevention of cardiovascular diseases among the indigenous Australians (Jennings, et.al., 2011). In relation to the general population, these indigenous Australians suffer from more health issues; they suffer from heart attacks at younger rates (10-15 younger) than other Australians; they have a 3-4 times rate higher incidence of diabetes as compared to other Australians (Jennings, et.al., 2011). The issue in budget cuts is not so much as to the harm brought to patients, but to whom such harm would likely befall. Trends seem to indicate that the most vulnerable population, including the women, the children, the elderly, the mentally ill, those under palliative and hospice care, and the minority population would likely bear such harm (Jennings, et.al., 2011). In the end, the unintentional impact of the policy and the decision is one which brings harm to the patient, harm which is even more dangerous as it affects the people who are vulnerable. In the end, the question is posed as to the actual purpose of government services – and to whom such services are meant. Budget cuts are beneficial In running a country and its related social services, resources are more often scarce. A crucial consideration is based on the fact that while the government may be able to allocate a certain percentage for health care, such provisions would severely impair the “availability of resources for other competing, and equally worthy, claims on national income” (Chisolm and Stewart, 1998, p. 57). Related to the concept of scarcity are the principles of sacrifice, choice, and prioritization. These have to be considered over and above emotional and sentimental considerations. Health care budget cuts are part of the concept of efficiency which is a primary principle and consideration in the allocation of limited resources. “Efficiency is first and foremost concerned with establishing that health care programmes are worthwhile, in the sense that their benefits exceed their costs (allocative efficiency); at a technical level, efficiency is concerned with ensuring that best use is made of the scarce resources channeled into these worthwhile programmes” (Chisolm and Stewart, 1998, p. 57). In applying its considerations in the health care system, choices and thorough considerations have to be made based on the cost: benefit framework and on welfare maximization. There is a need to consider which programs are most worthwhile and to allocate resources to such programs. In the end, they provide the greatest and the most efficient benefits for the most people. And this practice would bring less harm to the most number of people. One of the means being popularly adopted in the application of health budget cuts is health care rationing. This practice is about distributing meager resources based on effectiveness of medical intervention, cost-effectiveness of medical expense or allocation, need, and equity (Harrison and Hunter, 1994). In reviewing such policy against the principle of nonmaleficence, it is important to once again highlight the fact that this principle is founded on preventing harm from befalling others, in this case, patients and individuals involved in the delivery of health services (Hofman, 1994). Health rationing in health care can both be beneficial and detrimental to health care. For one it can ensure that limited resources would be sufficient to address health care needs. However, it also “leads inevitably to withholding potentially beneficial services and thus to doing some harm” (Hofman, 1994, p. 60). An assessment of the impact of these two possible impacts is important in establishing a thorough evaluation of the issue. Beauchamp and Childress point out that there are four conditions which must be satisfied in order to justify an act with both a good and a bad effect. The first condition is that the action itself, regardless of its impact must not be inherently wrong; it must be morally acceptable or at least morally neutral (as cited by Hofman, 1994). The second condition is that agent must mean only the good effects and not its bad effects as well and such bad impact can be predicted and tolerated, but must not be intended. In other words, such bad effects are allowed, but not be deliberately sought (as cited by Hofman, 1994). Third condition is that the bad impact must not be the means of achieving the good effect in the end. In effect, the good impact is the result of the action, not directly or indirectly by the bad effect. Finally, the good impact must not outweigh the evil being permitted (as cited by Hofman, 1994). A balance must therefore be achieved between the positive and the negative impact of the action (as cited by Hofman, 1994). These four conditions demonstrate the difficult challenge in complying with the principle of nonmaleficence in rationing health services (Hofman, 1994). In applying such principles, all four conditions may be used to rationalize health rationing; however, it may be possible to use intentionality and proportionality to justify health rationing. The first condition which basically sets forth that the action must not be inherently wrong. It is easy enough to argue that health rationing is about withholding services and is therefore inherently wrong and unacceptable. However, it is important to note here that resources are not infinite and ever flowing. It is therefore not appropriate to provide infinite and unlimited care to all citizens (Hofman, 1994). In considering the fact that rationing policies often lead to negative effects, such effects are not intentional, they can be anticipated and monitored efficiently (The Catholic Health Association, 1991). The last condition is also easily applicable in health rationing because rationing is an effective remedy in optimizing the delivery of health services. In effect, the negative impact of health rationing will be efficiently outweighed by its benefits for the common interests of the general population. Individual stand Based on the above discussion, I believe that health care allocations must be viewed from a bigger perspective. In the current age of limited resources, hard decisions have to be made and justified. These justifications must, in the end, be based on ideal provisions for the good of a greater number of people. I agree with the analysis of Beauchamp and Childress, and their analysis sets forth that the action must not be inherently wrong. Although budget cuts may at some point be considered wrong, resources are not unlimited. They are insufficient and cannot meet the needs of each and every person seeking its benefits. The greater harm and wrong is in allowing such resources to flow unlimited and unencumbered with hardly a thought for other needs and other people who may need it. The risk here is that people would grow dependent on such provisions of services without making a solid effort towards seeking health services based on their personal and hard-earned efforts. The idea in good governance is reciprocity between the people and its government authorities. The people cannot expect the government to support all their needs without making sacrifices to support their own needs. In the same way as individuals purchasing and paying for their insurance dues, the rest of the general population must consider such investments on their health. Health budget cuts do not cause harm to the people, it is the people themselves who place themselves in a position of being harmed by budget cuts. By not taking the necessary precautions to secure their health and their vulnerabilities, people are opening themselves to harm from difficult government decisions, including budget cuts. Admittedly, some of the vulnerable population is hardly given opportunities to safeguard their financial health situation. For which reason, the government needs also to make important considerations to improve their condition. Although I submit to the fact that health care budget cuts are a necessary evil to the health care practice, it must be a decision made with caution and after adequate considerations are made for the more vulnerable population. Relevance of the dilemma to nursing practice This dilemma has a significant impact on the nursing practice because they are the front liners in health delivery. Budget cuts would mean less staff hired to care for a growing number of patients (Rother and Lavizzo-Maurey, 2009). Less staff would also mean more work and more hours of work which have to be put in by these nurses. The danger of nurse burnout is a major risk for these nurses; it makes them less efficient and less accurate nurses with their proneness to medical errors registering at a higher rate (Wu, et.al., 2007). These errors are not beneficial, it may sometimes be deadly for patients and for the health care in general. Since budget cuts seem to be an inevitable part of the health care system, it is important for managers to ensure that their nurses are in healthy working conditions. The demand for strong management skills is crucial in the current health scenario (Finkler, et.al., 2007). Without sacrifices and intelligent considerations from health managers, bigger problems in relation to burned out nurses would arise. Managers also need to consider appropriate training sessions for newly hired nurses who can be hired at lower rates but who can still deliver the same expertise as the more experienced nurses. This dilemma also points out that more students have to be encouraged to join the nursing practice despite its demanding work load and lower pay rates. Recommendation for the future of the nursing profession For the future of the nursing profession, important considerations have to be made on its management. Nurse managers have to work with limited resources and on how to efficiently redistribute such resources while still maintaining quality care (Swansburg, 1997). In order for the nursing profession to efficiently deal with the issue of limited health resources, the nursing managers must also make the difficult decisions in the nursing profession. If older and less efficient nurses have to be let go in favor of younger and more capable nurses, then these decisions must be made. These are economic trade-offs which must be made in order to ensure that in the end, health services are delivered efficiently (Lawson, 2009). Investments must also be made by nurse managers towards training younger nurses who will be better equipped to deal with the longer and harder work hours. Just as government officials have to make difficult decisions in the allocation of limited resources, these same decisions must also be made by all people involved in health care – including nurses, nurse managers, and more importantly, the general population. The health budget cuts cannot be done away with because almost all areas of social services and governance are experiencing such budget cuts. In order to ensure the smooth running of a country, sacrifices have to be made by all sectors, including the health care sector. Works Cited Catholic Health Association (1991). With Justice for All? The Ethics of Healthcare Rationing, St. Louis: OCLC Chisolm, D. & Stewart, A. (1998). Economics and Ethics in Mental Health Care: Traditions and Trade-offs. The Journal of Mental Health Policy and Economics, volume 1: pp. 55–62 Finkler, S., Kovner, C., & Jones, C. (2007). Financial management for nurse managers and executives. New York: Elsevier Health Sciences Grant, E. (2011). Warning: Budget Cuts Could Harm Your Health. New Hampshire Public Radio. Retrieved 24 May 2011 from http://www.nhpr.org/warning-budget-cuts-could-harm-your-health George, H. (2011). Budget cuts would do real harm to Manchester’s needy. New Hampshire Union Leader. Retrieved 24 May 2011 from http://granitegrok.com/Budget%20cuts%20would%20do%20real%20harm%20to%20the%20needy.pdf Harrison, S. & Hunter, D. (1994). Rationing health care. New York: Institute for Public Policy Research. Hofman, P. (1994). Towards a just policy on healthcare rationing. Health Progress. Retrieved 24 May 2011 from http://journal.ics.ac.uk/pdf/1001005.pdf Jennings, G., MacMahon, S., & Donnan, G. (2011). Cuts to the NHMRC budget will undermine the health of all Australians — today and in the future. eMJA Rapid Online Publication. Retrieved 24 May 2011 from https://www.mja.com.au/public/issues/194_09_020511/jen10442_fm.pdf Lawson, A. (2009). Rationing in intensive care. Intensive Care Society. Retrieved 24 May 2011 from http://journal.ics.ac.uk/pdf/1001005.pdf Rother, J. & Lavizzo-Maurey, R. (2009). Addressing The Nursing Workforce: A Critical Element For Health Reform. Health Affairs, volume 28(4), w620–w624 Swansburg, R. (1997). Budgeting and financial management for nurse managers. Michigan: Jones & Bartlett. Wu, S., Zhu, Z., Wang, Z., & Wang, M. (2007). Relationship between burnout and occupational stress among nurses in China. Journal of Advanced Nursing, volume 59(3), pp. 233–239. Read More