Rationing Issues in Healthcare The concept of rationing healthcare is dealt with

Question

Rationing Issues in Healthcare The concept of rationing healthcare is dealt with on a daily basis. Healthcare rationing in the United States exists in various forms. Access to private health insurance is rationed based on price and ability to pay. Those not able to afford a health insurance policy are unable to acquire one, and sometimes, insurance companies prescreen applicants for pre-existing medical conditions and either decline to cover the applicant or apply additional price and medical coverage conditions. Access to state Medicaid programs is restricted by income and asset limits through a means test and to other federal and state eligibility regulations. Health maintenance organizations (HMOs) that commonly cover the bulk of the population restrict access to treatment via financial and clinical access limits. Using the South University Online Library, find a current article (no more than two years old) on rationing issues in healthcare. The article should also be peer-reviewed. Note: Peer-reviewed refers to articles reviewed and approved by authors' professional peers who are experts on the topic being discussed. After reading your article, summarize its contents and the main theme discussed. Then, answer the following questions:

•How is rationing defined and what criteria are offered to ration care?

•Discuss and apply at least one of the major ethical theories to the issue and the ethical decision-making process to the issue. •What do you feel the impact of the issue in the article will be on the healthcare industry? What can be done to ensure rationing is done fairly?

•Discuss the major codes of ethics of the stakeholders involved in the issue and how these codes will affect the decision-making process and the final decision.

•Examine and discuss the impact that the issue and the final decision will have on the stakeholders involved.

•Discuss any potential policy implications for the issue and the final decision.

Compile the summary and answers to the above questions in a 7- to 10-page Microsoft Word document.

Explanation / Answer

Ans:

Economically defined, healthcare rationing is simply limiting health care goods and services to only those who can afford to pay. In the United States this type of rationing affects about 15% of the population, who are either too poor to afford care or unwilling to buy care or simply uninsured.

Outcomes Research, Cost Containment, and the Fear of Health Care Rationing

Expectations are high for the Agency for Health Care Policy and Research, established by the 101st Congress to promote research on medical outcomes and develop guidelines for practice. Physicians and patients expect that such research will make it possible to sort out what works in medicine and learn how to make clinical decisions that reflect more truly the needs and wants of individual patients. Many business leaders, third-party payers, and policy makers believe that this effort will lead to the development of practice guidelines, which in turn will reduce the pressure for growth and produce a leaner, trimmer health care. .

An ethical framework for rationing health care.

This paper proposes an ethical framework for rationing publicly-financed health care. We begin by classifying alternative rationing criteria according to their ethical basis. We then examine the ethical arguments for four rationing criteria. These alternatives include rationing high technology services, non-basic services, services to patients who receive the least medical benefit, and services that are not equally available to all. We submit that a just health care system will not limit basic health care to persons unable to pay for it. Furthermore, justice in health care requires limiting publicly-financed non-basic health care, striving for equality in access to basic health care, and relying on medical benefit to ration non-basic health care.

Healthcare rationing in the United States exists in various forms. Access to private health insurance is rationed based on price and ability to pay. Those not able to afford a health insurance policy are unable to acquire one, and sometimes insurance companies pre-screen applicants for pre-existing medical conditions and either decline to cover the applicant or apply additional price and medical coverage conditions.Access to state Medicaid programs is restricted by income and asset limits via a means-test, and to other federal and state eligibility regulations. Health maintenance organizations (HMOs) that commonly cover the bulk of the population, restrict access to treatment via financial and clinical access limits.

The Patient Protection and Affordable Care Act passed in March 2010 will prohibit insurers from limiting coverage to people with preexisting conditions beginning in 2014, which will alleviate this type of rationing.

Some in the media and academia have advocated rationing of care to limit the overall costs in the U.S. Medicare and Medicaidprograms, arguing that a proper rationing mechanism is more equitable and cost-effective. The Congressional Budget Office(CBO) has argued that healthcare costs are the primary driver of government spending over the long-term.

Types of rationing[edit]

Rationing by Insurance companies[edit]

President Obama has noted that U.S. healthcare is rationed based on income, type of employment, and pre-existing medical conditions, with nearly 46 million uninsured. He states that millions of Americans are denied coverage or face higher premiums as a result of pre-existing medical conditions.

In an e-mail to Obama supporters, David Axelrod wrote: "Reform will stop 'rationing' - not increase it.... It’s a myth that reform will mean a 'government takeover' of health care or lead to 'rationing.' To the contrary, reform will forbid many forms of rationing that are currently being used by insurance companies."

A 2008 study by researchers at the Urban Institute found that health spending for uninsured non-elderly Americans is only about 43% of health spending for similar, privately insured Americans. These data imply rationing by price and ability to pay.

Fareed Zakaria wrote that only 38% of small businesses provide health insurance for their employees during 2009, versus 61% in 1993, due to rising costs.

An investigation by the House Subcommittee on Oversight and Investigations showed that health insurers WellPoint Inc., UnitedHealth Group and Assurant Inc. canceled the coverage of more than 20,000 people, allowing the companies to avoid paying more than $300 million in medical claims over a five-year period. It also found that policyholders with breast cancer, lymphoma and more than 1,000 other conditions were targeted for rescission and that employees were praised in performance reviews for terminating the policies of customers with expensive illnesses.[16]

Private and public insurers all have their own drug formularies through which they set coverage limitations which may include referral to the insurance company for a decision as to whether the company will or will not approve its share of the costs. American formularies make generalized coverage decisions by class with cheaper drugs in classes at one end of the scale and expensive drugs with more conditions for referral and possible denial at the other.[17] Not all drugs may be in the formulary of every company and consumers are advised to check the formulary before deciding to buy insurance.

The phenomena known as medical bankruptcy is unheard of in countries with universal health care in which medical copays are low. In the United States however, research shows that many bankruptcies have a strong medical component and that many of those who go bankrupt for a medical reason did have medical insurance. Medical insurance in the United States prior to the Affordable Care Act allowed annual caps or lifetime caps on coverage and, due to the high cost of care in the United States, it was not uncommon for the insured to suffer bankruptcy due to breaching these limits.

Rationing by price

A July 2009 NPR article quoted various doctors describing how America rations healthcare. Dr. Arthur Kellermann said: "In America, we strictly ration health care. We've done it for years...But in contrast to other wealthy countries, we don't ration medical care on the basis of need or anticipated benefit. In this country, we mainly ration on the ability to pay. And that is especially evident when you examine the plight of the uninsured in the United States."[19]

Rationing by price means accepting that there is no triage according to need. Thus in the private sector it is accepted that some people get expensive surgeries such as liver transplants or non life-threatening ones such as cosmetic surgery, when others fail to get cheaper and much more cost effective care such as prenatal care, which could save the lives of many fetuses and newborn children. Some places, like Oregon for example, do explicitly ration Medicaid resources using medical priorities.

Polling has discovered that Americans are much more likely than Europeans or Canadians to forgo necessary health care (e.g. not seeking a prescribed medicine) on the grounds of cost.

Rationing by pharmaceutical companies

Pharmaceutical manufacturers often charge much more for drugs in the United States than they charge for the same drugs in Britain, where they know that a higher price would put the drug outside the cost-effectiveness limits applied by regulators. American patients, even if they are covered by Medicare or Medicaid, often cannot afford the copayments for drugs. That is rationing based on ability to pay.

Rationing through government control

After the death of Coby Howard in 1987 the state of Oregon began a programme of public consultation to decide which procedures its Medicaid program should cover in an attempt to develop a transparent process for prioritizing medical services. Howard died of leukaemia which was not funded. His mother spent the last weeks of his life trying to raise $100,000 to pay for a bone marrow transplant, but the boy died before treatment could begin. John Kitzhaber began a campaign arguing that thousands of low-income Oregonians lacked access to even basic health services, much less access to transplants. A panel of experts, was appointed, the Health Services Commission, to develop a prioritized list of treatments. The state legislators decided where on the list of prioritised procedures the line of eligibility should be drawn. In 1995 there were 745 procedures, 581 of which were eligible for funding.

Republican Newt Gingrich argued that the reform plans supported by President Obama expand the control of government over healthcare decisions, which he referred to as a type of healthcare rationing. He expressed concern that, although there is nothing in the proposed laws that would constitute rationing, the combination of the following three factors would increase pressure on the government to ration care explicitly for the elderly:[23] An expanded federal bureaucracy, the pending insolvency of Medicare within a decade, and the fact that 25% of Medicare costs are incurred in the final year of life.

Princeton Professor Uwe Reinhardt wrote that both public and private healthcare programs can ration, rebutting the concept that governments alone impose rationing: "Many critics of the current health reform efforts would have us believe that only governments ration things.... On the other hand, these same people believe that when, for similar reasons, a private health insurer refuses to pay for a particular procedure or has a price-tiered formulary for drugs – e.g., asking the insured to pay a 35 percent coinsurance rate on highly expensive biologic specialty drugs that effectively put that drug out of the patient’s reach — the insurer is not rationing health care. Instead, the insurer is merely allowing “consumers” (formerly “patients”) to use their discretion on how to use their own money. The insurers are said to be managing prudently and efficiently, forcing patients to trade off the benefits of health care against their other budget priorities."

During 2009, former Alaska Governor Sarah Palin wrote against rationing by government entities, referring to what she interpreted as such an entity in current reform legislation as a "death panel" and "downright evil." Defenders of the plan indicated that the proposed legislation H.R. 3200 would allow Medicare for the first time to cover patient-doctor consultations about end-of-life planning, including discussions about drawing up a living will or planning hospice treatment. Patients could seek out such advice on their own, but would not be required to. The provision would limit Medicare coverage to one consultation every five years.However, Palin also had supported such end of life counseling and advance directives from patients during 2008.

Ezra Klein described in the Washington Post how polls indicate senior citizens are increasingly resistant to healthcare reform, due to concerns about cuts to the existing Medicare program that may be required to fund it. This is creating an unusual and potent political alliance, with Republicans arguing to protect the existing Medicare program, despite its position as one of the major entitlement programs they historically have opposed.The CBO scoring of the proposed America's Affordable Health Choices Act of 2009 (also called HR3200) includes $219 billion in savings over 10 years, some of which would come from Medicare changes.

Arguments for enhancing rationing processes

Peter Singer argued for enhancing the rationing processes:

"Rationing health care means getting value for the billions we are spending by setting limits on which treatments should be paid for from the public purse. If we ration we won’t be writing blank checks to pharmaceutical companies for their patented drugs, nor paying for whatever procedures doctors choose to recommend. When public funds subsidize health care or provide it directly, it is crazy not to try to get value for money. The debate over health care reform in the United States should start from the premise that some form of health care rationing is both inescapable and desirable. Then we can ask, What is the best way to do it?"

Rationing based on economic value added

A concept called "quality-adjusted life year" (QALY - pronounced "qualy") is used to measure the cost-benefit of applying a particular medical procedure. It reflects the quality and quantity of life added due to incurring a particular medical expense. The measure has been used for over 30 years and is implemented in several countries to help with rationing decisions. Australia applies QALY measures for its form of Medicare to control costs and ration care, while allowing private supplemental insurance.

Rationing using comparative effectiveness research

Medicare spending per person varied significantly across states in 2006

Several treatment alternatives may be available for a given medical condition, with significantly different costs yet no statistical difference in outcome. Such scenarios offer the opportunity to maintain or improve the quality of care, while significantly reducing costs, through comparative effectiveness research. Writing in the New York Times, David Leonhardt described how the cost of treating the most common form of early-stage, slow-growing prostate cancer ranges from an average of $2,400 (watchful waiting to see if the condition deteriorates) to as high as $100,000 (radiation beam therapy):[30]

Some doctors swear by one treatment, others by another. But no one really knows which is best. Rigorous research has been scant. Above all, no serious study has found that the high-technology treatments do better at keeping men healthy and alive. Most die of something else before prostate cancer becomes a problem.

According to economist Peter A. Diamond and research cited by the Congressional Budget Office (CBO), the cost of healthcare per person in the U.S. also varies significantly by geography and medical center, with little or no statistical difference in outcome.[31]

Although the Mayo Clinic scores above the other two [in terms of quality of outcome], its cost per beneficiary for Medicare clients in the last six months of life ($26,330) is nearly half that at the UCLA Medical Center ($50,522) and significantly lower than the cost at Massachusetts General Hospital ($40,181)...The American taxpayer is financing these large differences in costs, but we have little evidence of what benefit we receive in exchange.

Comparative effectiveness research has shown that significant cost reductions are possible. Office of Management and Budget (OMB) Director Peter Orszag stated: "Nearly thirty percent of Medicare's costs could be saved without negatively affecting health outcomes if spending in high- and medium-cost areas could be reduced to the level of low-cost areas."[32]

President Obama has provided more than $1 billion in the 2009 stimulus package to jump-start Comparative Effectiveness Research (CER) and to finance a federal CER advisory council to implement that idea. Economist Martin Feldstein wrote in the Wall Street Journal that "Comparative effectiveness could become the vehicle for deciding whether each method of treatment provides enough of an improvement in health care to justify its cost."

Rationing as part of fiscal discipline

Former Republican Secretary of Commerce Peter G. Peterson indicated that some form of rationing is inevitable and desirable considering the state of U.S. finances and the trillions of dollars of unfunded Medicare liabilities. He estimated that 25-33% of healthcare services are provided to those in the last months or year of life and advocated restrictions in cases where quality of life cannot be improved. He also recommended that a budget be established for government healthcare expenses, through establishing spending caps and pay-as-you-go rules that require tax increases for any incremental spending. He has indicated that a combination of tax increases and spending cuts will be required. He advocated addressing these issues under the aegis of a fiscal reform commission.

Arizona recently modified its Medicaid coverage rules because of a budget problem which included denying care for expensive treatments such as organ transplants to Medicaid recipients, including those who had previously been promised funding.[34] MSNBC's Keith Olbermann and others have dubbed Governor Jan Brewer and the state legislatures as a real life death panel because many of those poor people who are now being denied funding will lose their lives or have a worsened outlook as a result of this political decision.

Old-age-based health care rationing

In America, the discussion on rationing health care for the elderly began to take root in 1983 when economist Alan Greenspan asked "whether it is worth it", referring to the use of 30% of the Medicare budget on 5 to 6 percent of those eligible who then die within a year of receiving treatment. In 1984 then Democrat governor of Colorado Richard Lamm was widely quoted (though he argues he was mis-quoted) as saying the elderly "have a duty to die and get out of the way." Medical ethicist Daniel Callahan's 1987 Setting Limits: Medical Goals in an Aging Society discusses whether health care should be rationed by age. In Callahan's view old people are "a new social threat" whom he considers selfish and his remedy for this threat is to use age as a criterion in limiting health care. Callahan's book has been widely discussed in the America media including the New York Times, the Washington Post, the Wall Street Journal and in "just about every relevant professional and scholarly journal and newsletter." One of the major arguments against such age-based rationing is the fact that chronological age by itself is a poor indicator of health.[38] Another major argument against Callahan's proposal is that it inverts the Western tradition by making death a possible good and life a possible evil, which means, according to Amherst College Jurisprudence professor Robert Laurence Barry, that Callahan's view amounts to "medical totalitarianism".One book-length rebuttal to Callahan's views from a half dozen professors who held a conference at the University of Illinois College of Law in October 1989 can be found in 1991's Set No Limits: a Rebuttal to Daniel Callahan's Proposal to Limit Health Care edited by Robert Laurence Barry and Religious studies University of Illinois at Urbana-Champaign visiting professor Gerard V. Bradley.

Consequences of not controlling healthcare costs

Medicare and Medicaid Spending as % GDP

The Congressional Budget Office reported in June 2008 that:[8]

"Future growth in spending per beneficiary for Medicare and Medicaid—the federal government’s major health care programs—will be the most important determinant of long-term trends in federal spending. Changing those programs in ways that reduce the growth of costs—which will be difficult, in part because of the complexity of health policy choices—is ultimately the nation’s central long-term challenge in setting federal fiscal policy...total federal Medicare and Medicaid outlays will rise from 4 percent of GDP in 2007 to 12 percent in 2050 and 19 percent in 2082—which, as a share of the economy, is roughly equivalent to the total amount that the federal government spends today. The bulk of that projected increase in health care spending reflects higher costs per beneficiary rather than an increase in the number of beneficiaries associated with an aging population."

In other words, all other federal spending categories (e.g., Social Security, Defense, Education, and Transportation) would require borrowing to be funded, which is not feasible.

President Obama stated in May 2009: "But we know that our families, our economy, and our nation itself will not succeed in the 21st century if we continue to be held down by the weight of rapidly rising health care costs and a broken health care system...Our businesses will not be able to compete; our families will not be able to save or spend; our budgets will remain unsustainable unless we get health care costs under control."

Public Health Ethics in Practice

As demonstrated by emergency preparedness, leadership in public health practice requires an ongoing approach to ethics that focuses on two dimensions of practice-the professional relationships of officials developed over time with their communities and the ethical aspects of day-to-day public health activities. Relationship-building activities, such as collaboration and deliberation with community stakeholders, provide opportunities for public health officials to integrate professional values into everyday practice. When animated by public health principles, such as justice and respect for individuals and diverse cultures, these activities may be more important for biopreparedness than having legal authority, because over time they engender community trust and nurture civic cooperation. A growing body of empirical literature provides evidence for "a link between perceptions of trustworthy government and citizen compliance[horizontal ellipsis]" and some studies explicitly address the importance of "the psychological interactions between the governed and their governors."1(p492) Other recent studies describe possible components of trust, such as perceived competence, consistency, fairness, and openness on the part of government officials, as well as, in a participatory democracy, an active public.2 For public health officials, empirical evidence about public involvement, deliberation, and political legitimacy can be helpful, particularly for designing different strategies or ways to encourage and strengthen public engagement, for example, town hall meetings and focus groups.3

Ethics, however, provides yet another form of inquiry--it addresses an important complementary question, that is, which moral norms should guide our behavior and why? For example, when allocating scarce medical resources in an emergency, which norms should guide decisions, treat on the basis of the most good for the greatest number, or treat the most vulnerable and sickest first?

In general, ethics as a discipline examines such questions as how we should live and treat one another, and how, all things considered, should we act. Public health officials, who are both government officials with obligations to the public and also healthcare professionals with their own professional norms, face ethical tensions and conflicting obligations when deciding how to act in many situations. Education and competencies in at least three different spheres of ethics may be helpful in practice, by providing, at a minimum, frameworks and principles to structure analysis and discussion in health departments and with community stakeholders.

Professional ethics, which focuses on the professional relationship between the official and the community. What does it mean to be a professional? The term profession generally refers to a vocation or occupation that has a practice with specialized training, a commitment to serving clients, self-regulation, and often a public purpose or social function. Some suggest that the professions and society negotiate the terms of their relationship to satisfy the profession's interest in autonomy and the public's interest in accountability.4 Most professions have at least an implicit professional morality, and in recent years many groups are developing or strengthening explicit codes of conduct and values to educate and transmit moral guidelines about professional relationships and actions.

In public health, the professional relationship between the public health professional and client is complex. Public health officials act as both government officials with police powers and healthcare professionals with health as a primary public good. In a democracy, public health officials are like physicians to the community with an ethical duty to engage in a consent process that involves transparency and public accountability and yet have the duty to override the decisions of individuals who put the health of the public at risk. Implicit in the traditional social obligations of professions, including public health, are tensions because a professional often owes obligations to a number of parties, including individuals, numerous groups in society, the public at large, other professionals, and government authority.

Managing the tensions that arise in emergency preparedness and public health practice is made even more difficult by the fast changing social and political landscape and the evolving understanding of public health. There has been a shift in emphasis between the 1988 Institute of Medicine report on public health,5 which emphasized strengthening of governmental public health agencies, and the 2002 Institute of Medicine report, The Future of the Public's Health in the 21st Century,6 which focuses on the public health system as a "complex network of individuals and organizations that have the potential to play critical roles in creating the conditions for health." This new context requires that public health officials be managers and community leaders who often work in large public health agencies and in partnerships and through collaborations with numerous public and private stakeholder groups and citizens--"who have widely varying values" that often shift over time as the political and social context evolves.7(p110)

A vision of public health as "healthy people in healthy communities" expands the scope of public health to include behavioral and socioeconomic factors that require the development of long-lasting community action and community relationships to affect change and have any impact. In addition, whereas most states have updated public health laws in recent years, commentators emphasize that legal authority should be a last resort in public health and that public health action in a liberal democracy should rely not on force but on persuasion and should express, not impose, community.8

Relationship building, whether between public health officials and the public they serve or between and among community partners, is not merely instrumental, but rather the substance of public health work, particularly in emergency preparedness. Other related contemporary roles of public health professionals also include that of translators, mediators, negotiators, educators, or caretakers.9 Commentators have suggested that "(B) building a community of stakeholders--educating and facilitating individuals and entities to see themselves as 'connected through health'-is central to the professional identity of public health officials."10(p1213)

These values of professionalism are captured in the Public Health Code of Ethics discussed in the later sections of this article. Codes of ethics have been used by professions throughout history to provide a source of guidance about right and wrong behavior and good and bad practice. The recent development of a code for public health demonstrates the field's commitment to enriching its identity and role and its relationship with the public. The principles elucidated in the public health code can serve as an important frame of reference for public health officials when they communicate with the public about their role and the underlying goals of their activities. The code can provide a foundation for principle-based leadership.

Organizational ethics, which focuses on the mission, values, and systems within an agency that creates a climate for ethical behavior, practices, and policies. Organizational ethics involves providing public health leaders and workers with training, tools, and organizational structures, such as committees, to help them recognize the ethical dimensions of their work and integrate the agency's values into the performance of their tasks. Some empirical research, primarily in the business context, suggests that ethical codes of conduct and ethics training within an organization can be associated with changes in behavior and decision making (see A Review of Empirical Studies Assessing Ethical Decision Making in Business11 and the book, Built to Last: Successful Habits of Visionary Companies12). More empirical research on organizational ethics is needed.13 Ethicists, however, have provided much normative guidance about the ways organizations can explicitly include ethical analyses into organizational activities, such as compliance, risk management, quality improvement, and evaluation measurements for employee performance review and agency accreditation.14 Later in this article, principled leadership in practice will explore opportunities for integrating ethics into day-to-day practice.

Public policy ethics, which can offer a deliberative framework and process that leads to public justification. Some issues that arise in public health practice, such as providing and allocating scarce funds for particular interventions, are policy questions that must be resolved in the political arena. This process involves the engagement of community stakeholders and the public at large in the development of political consensus and support for public health activities. Public justification is a requirement of public officials who are accountable to the public they serve for the ethical reasons underlying their decisions and policies. Although public health professionals' values and codes of ethics can be part of the public deliberation about policy, justifications in any particular case will be based on an analysis of the benefits and burdens of particular options and of the interests and moral claims of all the stakeholders. The following framework provides one approach to analysis by posing questions to help frame deliberation with the public or within the health department management team.15

1. Analyze the ethical issues in the situation:

* What are the public health risks and harms of concern?

* What are the public health goals?

* Who are the stakeholders, and what are their moral claims?

* Is the source or scope of legal authority in question?

* Are precedent cases or the historical context relevant?

* Do professional codes of ethics provide guidance?

2. Evaluate the ethical dimensions of the alternate courses of public health action:

* Utility: Does a particular public health action produce a balance of benefits over harms?

* Justice: Are the benefits and burdens distributed fairly (distributive justice), and do legitimate representatives of affected groups have the opportunity to participate in making decision (procedural justice)?

* Respect for liberty: Does the public health action respect individual choices and interests (autonomy, liberty, and privacy)?

* Respect for legitimate public institutions: Does the public health action respect professional and civic roles and values, such as transparency, honesty, trustworthiness, promise-keeping, protecting confidentiality, and protecting vulnerable individuals and communities from undue stigmatization?

3. Provide Justification for a particular public health action:

* Effectiveness: Is the public health goal likely to be accomplished?

* Proportionality: Will the probable benefits of the action outweigh the infringed moral considerations?

* Necessity: Is it necessary to override the conflicting ethical claims to achieve the public health goal?

* Least infringement: Is the action the least restrictive and least intrusive?

* Public justification: Can public health agents offer public justification for the action or policy, on the basis of principles in the Code of Ethics or general public health principles that citizens and in particular those most affected could find acceptable in principle?

Emergency Preparedness in Public Health as an Illustration

Emergency preparedness, then, may require public health officials to first and foremost take an active role in building a community of stakeholders, integrating ethics into day-to-day practice that involve emergency-preparedness tasks, and generating debates on such policies as rationing in an emergency. The fire department metaphor for public health provides an understanding of this role, according to commentators,

by suggesting that drills to prepare for and challenge our potential responses, are appropriate preventive measures. Drills are important not only as instructive devices for practicing activities (such as "know the nearest exit"), but also because, in the context of biopreparedness and state power, we need to "prepare" our civic responses when challenged as a community. The purpose of public debate is not merely to have fair procedures or reach consensus on any one course of action, but rather to build and strengthen our civic commitment to continued cooperation, essentially to sustain a collaborative relationship over time. Most importantly, deliberation actively engages the public in preparation and response as partner and full participant in public health.16(p115)

A brief examination of a community's need to develop guidelines for rationing scarce medical resources in a public health emergency illustrates why drawing on the three spheres of public health ethics is helpful. The Implementation Plan for the National Strategy for Pandemic Influenza, released by the White House in May 2006,17 describes the way public health agencies at all levels of government are expected to work with hospitals and private healthcare providers in the community to address the medical needs of citizens. The plan also describes the challenges that will arise with the expected surge in medical need. Here is how the plan presents the situation,

if a pandemic overwhelms the health and medical capacity of a community, it will be impossible to provide the level of medical care that would be expected under prepandemic circumstances. It may be necessary because of hospital overcrowding, to establish prehospital facilities and alternate-care sites to provide supplemental capacity. In some circumstances, it may be necessary to apply triage principles in the hospital to regulate, which patients gain access to intensive care units (ICUs) and ventilators and it is likely that vaccines, pharmaceuticals, and other medical material will also be rationed[horizontal ellipsis]. As in all situations involving the allocation of scarce medical resources, the standard of care will be met if resources are fairly distributed and utilized to achieve the greatest benefit. In a pandemic, hospital and ICU beds, ventilators, and other medical services may be rationed. As in other situations of scarce medical resources, preference will be given to those whose medical condition suggests that they will obtain greatest benefit from them. Such rationing differs from approaches to care in which resources are provided on a first-come, first-served basis or to patients with the most severe illnesses or injuries[horizontal ellipsis]. In all cases, the goal should be to provide care and allocate scarce equipment, supplies, and personnel in a way that saves the largest number of lives[horizontal ellipsis]. In making adjustments in the delivery of care because of constrained resources, individual autonomy, privacy, and dignity should be protected to the extent possible and reasonable under the circumstances. Finally, clear communication with the public is essential before, during, and after a mass casualty even such as a pandemic.17(p110)

Simply put, what is the role of the local health department official in preparing a community for hospital triage (as described above) during a public health emergency?

Drawing on an understanding of and competencies in the three spheres of public health ethics, officials' effectiveness in addressing emergency-preparedness questions such as these will be affected by (1) the strength of their ongoing professional relationships with the public and community stakeholders, enriched by codes of ethics or ethical principles; (2) the expertise they have demonstrated and trust they have built through the ethical management of day-to-day public health activities over time; and (3) the public's involvement in the development of both the rationing policies and guidelines and the public justification for them.

Because biopreparedness includes policy making in the political sphere, public justification will play a key role because public consent is the source of moral authority and legitimacy for public decision making in public health. As one political theorist suggests, public authorities should reflect the moral understanding of the group in whose name any decision is being taken and justify decisions in a way the public will find persuasive because moral judgments, unlike scientific judgments, are "everyone's job" in society.18

At a minimum an official's role would include convening stakeholders and coordinating collaborations and forums for deliberation with many partners and community members. In addition, public health officials may take a more active role as conveyers of public information, educators, or partners with other government officials in forging public consensus about guidelines on rationing and on the options for securing some type of public consent to rationing in an emergency. Requirements for public engagement could range from mere notice to the public through the media, to invitations to the public to participate in community deliberations and hearings, to conducting community focus groups and surveys about public values that should guide rationing, to the establishment of community ethics boards that could have either rotating memberships such as a jury or predominantly community experts as permanent members. Each community must address which of the options for community engagement is appropriate, on the basis of such factors as community values and trust.

Emergency preparedness illustrates that effective public health leadership and practice are enriched by professional ethics and stronger public health relationships developed over time, by local agencies that have integrated ethics into their organizational structure and management, and by communication, deliberation, and public justification with the public as partner. Attention to the ethical dimensions in these activities, in effect, extends and deepens the meaning of "public" in public health. The goal is a stronger, trusting public that collaborates and cooperates with government public health officials.

Principled Leadership in Practice

The emergency-preparedness case we have described illustrates that ethical decision making is not an isolated case, but rather takes place in a particular context and community. As we have discussed in the previous section, public health officials committed to incorporating ethics into practice must create an organizational context within their agencies that is grounded in ethics. This could be accomplished by tying employee-performance standards to ethical principles and by encouraging staff to integrate ethics into their daily work by developing goals, objectives, and measurable outcomes that are based on public health values and principles. We describe this as principled leadership. The first part of this section highlights some of the ethical implications of daily public health activities. The second part describes how public health officials can incorporate ethical processes throughout the work of their organizations by drawing on the Code of Ethics to provide a guide and language for deliberation.

Protecting the public: Recognizing and responding to public health threats

Surveillance

The nature of governmental public health work, specifically activities like surveillance, community notification, and other disease control efforts, requires that public health officials make trade-offs between individual rights and community benefits virtually every day. Given the responsibility of local and state public health departments to protect the public, the first step for organizations committed to ethical practice is to recognize public health threats promptly. Clues to the presence of public health threats can come from several sources, including the notifiable disease-notification system, disease registries, or anecdotal reports, such as calls from emergency-department physicians. Decisions to set the response sensitivity at different levels, such as statistical requirements (incidence above a set level), staff intuition or supervisor mandate or decisions to require staff to collect additional data, with the attendant delay in response, can have ethical implications. In addition, any personal conflicts of interest could influence whether public health officials are willing to acknowledge the existence of a threat19

Once public health officials and their staff deem it necessary to collect additional information, they have several methods available, all involving some form of active surveillance, such as outbreak investigations or community surveys. The problem they wish to characterize could be short term, such as a communicable disease, or long term, such as youth obesity. Ethical considerations underlie many of the decisions involved in active surveillance efforts, including which populations or groups to survey and which specimens or data to collect. Examples include determining whether the active surveillance process threatens confidentiality or unfairly creates burdens or stigma for specific populations, groups, or individuals.

All public health surveillance activities involve trade-offs between individual privacy (the interest in restricting access to personal information and body specimens) and confidentiality (legal obligations to prevent redisclosure of private information) and the public's right to know about problems that could affect them. Although public health law allows public health officials to gather notifiable disease information without individual consent, the nonconsensual nature of these activities entails that public health officials should give particular attention to the privacy and confidentiality of individuals from whom they gather data. When collecting data, ethical considerations require public health officials to collect only data elements and specimens necessary for disease control or health promotion efforts and to remove personal-identifying information from the dataset once it is no longer useful.

When conducting case-control investigations into outbreaks of either notifiable conditions or diseases of uncertain origin, public health officials must gather information from healthy people as well as ill people to help them identify associations between exposure and illness. Most state laws give local public health officials the authority to collect data from ill people without conducting formal, explicit informed consent. However, public health authority to collect data without consent from healthy people serving as controls, such as those identified eating at an affected restaurant through credit card receipts, is unclear.

Data analysis and reporting

Once surveillance activities have collected information, public health officials have additional ethical considerations when performing data analysis and when reporting the data. Ethical considerations in data analysis include ensuring data quality and accounting for data-quality limitations in the analysis, determining statistical thresholds for defining significance, and ensuring confidentiality, especially when small numbers are involved. Even when reporting aggregated data, public health officials must balance the public's need for information with the possibility that their analysis could stigmatize specific populations or reduce property values, for example, when identifying populations affected by toxic emissions from a nearby power plant. In addition, when reporting associations between exposure and illness, public health officials must ensure that those who use the data, including the media and policy makers, avoid drawing inappropriate conclusions regarding cause and effect.20 While spending time on these considerations, public health officials must still endeavor to ensure to report their findings promptly, especially to individuals and community partners who contributed information to the surveillance process, especially if they wish to maintain trust with affected communities.

Public health interventions

After gathering information and conducting the analysis, public health officials will consider potential responses, each likely to have ethical implications. Responses might include isolating someone with a communicable disease, such as tuberculosis, restricting the movements of healthy people exposed to a communicable disease such as severe acute respiratory syndrome (quarantine), or restricting children from school until they obtain immunizations. All of these decisions, which invoke the public health police powers, involve balancing individual liberties with community benefits. Scarce resource allocation decisions, such as determining who will receive antiviral medications during a flu pandemic, involve working with community stakeholders in developing an equitable, transparent system for distribution and allocation.

Governmental public health officials have many interventions at their disposal ranging from health education, to regulation, and to taxation. All of these interventions have ethical implications.

The objective of public health education campaigns, such as tobacco and substance abuse campaigns, is to change individual health behaviors and community social norms. Even if these campaigns provide accurate information, they raise ethical questions about the role of government in doing so. One framework for ethical consideration of these campaigns distinguishes between persuasion, defined as appeals to reason that enhance individual autonomy, and manipulation (psychological manipulation or manipulation of information), which does the opposite.21 Other ethical considerations in health promotion campaigns include whether public health officials involve community stakeholders in determining the topic of the campaign, the nature of the campaign itself, including marketing materials, and whether public health officials share campaign goals with the target population.

Regulatory interventions present another set of ethical considerations. Some examples include regulating whether health-promoting or health-reducing substances, such as tobacco, are present in specific areas, decisions affecting the flow of information related to health and behavior, and the prescription of sanctions to individuals to promote desired behavior and deter undesired behavior. Using sanctions to require compliance raises concerns about paternalism and the trade-offs between individual liberty and community benefit, and public health officials must provide justifications for suppressing the flow of information.

When implementing interventions that may place individual liberties at odds with community benefits, public health officials must consider three factors:

* Whether the intervention is the least restrictive of individual rights.

* Whether public health officials have attempted to reduce any negative effects of these restrictions, such as providing food and water for quarantined individuals, or providing directly observed therapy for tuberculosis in a confidential location with incentives.

* Whether the burdens involved do not disproportionately affect a minority or otherwise vulnerable population.

Program evaluation

Governmental public health programs involve the use of scarce public resources. Therefore, public health officials have an obligation to ensure that they use these resources efficiently and effectively. For example, public health officials should be able to demonstrate how their interventions address problems identified through surveillance. Such program evaluation requires data collection without any formalized consent process, and public health officials should consider individual privacy and confidentiality for these activities. Some potential solutions involve collecting the minimal amount of data necessary and removing personal identifying information as soon as possible to do so without compromising the evaluation.

Clearly, governmental public health officials make public health decisions involving ethical trade-offs virtually every day. Given the frequency and consequences of these decisions, public health officials might benefit from ethical guidelines or tools to help frame their deliberations.

Ethics Tools: Codes of Ethics

Physicians have long recognized the value of using ethical codes in making medical decisions. The American Medical Association established a Code of Ethics at its first meeting in Philadelphia in 1847.22 In helping physicians practice, the ethical principles underlying these codes stress the responsibility physicians have for improving the health of their individual patients, although improving the health of society is a secondary concern.

Medical ethics and public health ethics

Like physicians, local and state public health officials are interested in improving the health of people they serve. However, as already identified, governmental public health practice activities have unique features that medical codes of ethics do not address. Compared to physicians, the foremost concern of public health practitioners is the health of entire community, although individual health is also a concern. To improve the community's health, state and local public health officials frequently use public health law, regulations and policies based on the police power of states. The consideration of community health as primary and the use of police powers to enforce public health measures can sometimes place public health officials at odds with individuals including the physicians caring for them.

Although public health law tells public health officials what they can do, it does not give guidance to public health officials regarding what they should do in specific situations, especially when officials must balance community concerns against individual liberties and property rights. In addition, public health law varies by state, making decision making based on legal authority, unique across jurisdictions. In many specific situations, legal authority may be ambiguous, leaving public health officials without clear guidance regarding actions they should take and requiring them to offer ethical justifications and reasons for their actions.

Recognizing the need for a tool that could help public health officials make decisions unique to them, the Public Health Leadership Society (PHLS) developed the Public Health Code of Ethics (2) (see Box 1). To obtain broad input in developing the code, PHLS consulted with Association of State and Territorial Health Officials and National Association of County and City Health Officials leadership, held focus groups with public health practitioners, and presented drafts of the Code at American Public Health Association town hall meetings.

  

BOX 1. No caption available.

In creating the code, PHLS members and their partners recognized that decisions based solely on epidemiology or on public health legal authority do not always have the best outcomes. Instead, public health officials should always question whether a given action is necessary, whether there are less restrictive alternatives, and whether they can justify their actions to their community constituents. Ethical codes provide a systematic means to balance trade-offs between individual and community interests as well as systematic guidance for justifying public health interventions on the basis of what is good and right for health and social welfare. The use of ethical principles in guiding decision making recognizes that processes, doing things right, are as important as outcomes, or doing the right things. In addition, the use of ethical principles recognizes that public health officials are accountable to the communities they serve, that the law alone does not justify specific actions, and that public health officials cannot perform their work adequately without the public's trust.

The Code of Ethics helps public health leaders question whether the benefits, such as reducing the transmission of illness or ensuring the availability of critical services, such as antiviral medications for hospitalized patients with pandemic influenza, justify the means, such as restricting the movement of someone with tuberculosis or restricting availability of antiviral medications for prophylaxis. Principle 4, for example, might focus attention on the way particular actions affect basic resources for disenfranchised community members. The Code of Ethics is a valuable tool because public health officials can use the same principles consistently when deliberating about various decisions. Consistency of values over time, on different issues, and throughout the organization builds community trust.

Recognizing the importance of knowledge and skills in ethics, the American Association of Schools of Public Health included professionalism as one of the core competency domains for students graduating with MPH degrees. American Association of Schools of Public Health defined professionalism as "the ability to demonstrate ethical choices, values, and professional practices implicit in public health decisions; consider the effect of choices on community stewardship, equity, social justice and accountability; and to commit to personal and institutional development." The seventh competency within this domain is the ability "to apply basic principles of ethical analysis (eg, the Public Health Code of Ethics, human rights framework, other moral theories) to issues of public health practice and policy"

Hearth policy implication

The United States currently spends close to 1/5th of its Gross Domestic Product on healthcare services (i.e. $2.7 trillion). Continued growth of these costs will put immense strain on future economic viability and crowd out spending on other federal government activities such as national defense, homeland security, transportation, education, and energy. Notwithstanding this fiscal challenge, it is important to realize that the provision of healthcare services – regardless of a country’s economic outlook – cannot be a limitless spending entitlement. Despite public disfavor for the term "rationing" when it comes to the politics of healthcare reform, it is axiomatic that economic goods such as healthcare services are not truly based on an inelastic pricing and demand model. Due to the seemingly endless nature of the technological and pharmaceutical intervention possible with healthcare services, rationing is inevitable in order to preserve the utilitarian value of the societal benefit.

No country can afford to provide limitless healthcare services to its citizens. Even if all of the waste was eliminated from a country’s healthcare system so that economic resources could be appropriately redirected, counteracting forces such as population growth, an aging population, and advances in medical technology would still cause medical expenditures to continue to increase at a rate faster than inflation (Feldstein, 2003). As no country can afford to spend unlimited resources on medical services, each society must choose some mechanism to ration or limit access to medical services.

Throughout American history, centrally-planned rationing has generally been thought of to be an acceptable control mechanism for all other goods or services outside of healthcare, if absolutely necessary to preserve public order and economic equity. Previous examples include the rationing of food, gasoline and other goods in World War II and the rationing of gasoline in the 1970’s. Although these instances of rationing were an imposition on the American people, none of them led to civil unrest. However, the same cannot be said in cases where healthcare services are rationed. Since healthcare services in this country are deemed as an absolute societal right rather than an individual privilege, any attempt to limit access to specific individuals based on overall equity or societal economy will be met with a resounding backlash.

To better counter the societal zeitgeist against rationing in terms of healthcare, it is imperative for Americans to realize that rising healthcare costs and their consequences for Medicare and Medicaid constitute our nation’s central fiscal challenge. Without significant economic changes to health policy, the government’s spending on healthcare is on a path that cannot be sustained. Rationing offers a potentially equitable solution to lower overall healthcare spending because resources can be allocated to a precise algorithm based on some widely shared social ethic. For example, children can be given a preference over the aged or the poor could be favored over the wealthy. With a candid and open dialogue with the electorate, rationing is this context could be deemed by society to be the most righteous way to allocate scarce resources, even though the political challenges posed by special interest groups could be insurmountable.

Given that demagoguery occurs anytime there is a health policy debate about controlling costs, policymakers are averse to making any decisions of resource allocation at the expense of one stakeholder group over another - even if these decisions favor the young over the old or the poor over the rich. Alarmist rhetoric associated with fears of healthcare rationing (e.g. ‘death panels’) tends to keep most cost-control innovations at bay. The intransigence of extremists within both political parties, coupled with the lack of political will for most federal legislators, has created an incredibly difficult climate to make tough discretionary decisions of resource allocation. Granted, the

The stonewalling of the federal legislative branch towards the promulgation of rationing measures in the Medicare and Medicaid programs (for expensive procedures with marginal benefit) is unfortunate. It is due to a result of a lack of fiscal fortitude, emotionally-driven politics based on re-election concerns that trump public good, and rhetoric from special interest groups that clouds public judgment. The hyperbole associated with the "r-word" prevents rational discourse in American society. In truth, rationing is an inescapable part of economic life. Even in the United States, the richest society in human history, there has to be some modicum of restraint to preserve the public good.

While defining ethics competencies for MPH graduates is helpful, these individuals make up a small proportion of the public health workforce. Public health officials engaged in principled leadership must ensure that ethics is considered at all levels of their organizations. As health departments prepare for accreditation, public health workers might integrate ethics codes and principles into the required agency evaluation plan as well as into particular activities. For example, during preparedness exercises, public health officials could ensure that the incident-management system incorporates ethical principles and performance measures based on them into response decisions. By doing so, by providing moral as well as scientific and political justifications for their public health activities, we believe that state and local public health departments will engender community trust and enrich their practice, thereby improving the health of their communities.

BOX 1. No caption available.

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