Professional and Business Ethics in Health Care
dr. Nur Azid Mahardinata Center for Bioethics and Medical Humanities Faculty of Medicine, Universitas Gadjah Mada HOW CAN WE EXPLAIN THIS PHENOMENA?
Background Medical professional is facing a decreasingprofessionalism and increasing ethical problemsaround the globe Charles Dougherty: General features of the pervasive hold of commercialismin medicine include an increase in competition and declinein professionalism among physicians, a view of healthcare as commodity and patients as consumers, and ageneral depersonalization of doctor-patient relationshipincluding dilution of the tradition of physician as patientadvocate HOW CAN WE EXPLAIN THIS PHENOMENA? FIRST: The Theory of Market
Developed by Adam Smith: Economic man, self-interested, and fundamentallyasocial, motivated by an insatiable desire to improve hismaterial condition, is the model that explains humanmotivation and action The special characteristics of healthcare market isboth Private as well as Social/Public domain Therefore, health care business is unique. It mustbalance the obligation to care for others with thenecessity of making a profit as a business. Pharmaceutical Industry
Patient Care Profit Making Hospital Pharmaceutical Industry Physician Government Patient and Families What is profitable to Businesses in the Healthcare industry:
Selling Medicine/Drugs Selling Medical Supplies Hospital equipment Lab equipment Selling Medical Services Patient care Nursing home care Home care New Health Care Technology Market Driven Care Advantage Disadvantage Incentive for innovation
Incentive for efficiency Less governmentintervention Alienate physicians Undermine patient trustof physicians Hurt academic medicalcenters and theresearch establishment More patients withouthealth care coverage. Public Cost of Poor Health
Higher disease burden Longer time to recover from sickness Shorter time to work (become productive economically and socially) Lower life expectancy What is not as directly profitable is: PreventionAn ounce of prevention is worth a pound of cure
But companies cant make much money from preventing diseases Therefore, healthcare should be managed by the people and for the people How Market Driven Healthcare Cuts Costs
recruit the healthiest patients excluding the sickest rationing care by making it inconvenient to obtain denying care by a variety of mechanisms. Physicians Dilemma in Market Driven Healthcare
As Caregiver: provide a wide range of services, recommend the besttreatments improve patients' quality of life As Efficiently keeping expenses to a minimum: limit the use of services increase efficiency shorten the time spent with each patient use specialists sparingly Managed healthcare plans Good of Patient vs ..
(1) the good of all the other patients served by the plan (2) the good of the plan and the organization themselves (3) the self-interest of the physician. from Edmund Pellegrino Second: Stakeholder Theory:
Who are the Stakeholdersfor a HealthcareOrganization? From Pat Werhane: Business Ethics, Stakeholder Theory, and the Ethics of Healthcare in Organizations The Investor: Pharmaceutical Industries
The pharmaceutical industry in 2006 was worth US$ 643 billion. Total pharmaceutical sales from the top 10 companies accounted formore than 40% of the total market (see table). Pharmaceutical Industry as Investors
Irrational Use of Drugs In 2005, the Indian NationalCommission on Macroeconomicsand Health labeled 10 out of 25top selling brands of medicinesin the country as being eitherirrational or non-essential orhazardous. Pharmaceutical Industry as Investors
Questionable New Drugs A survey in April 2005 by the French journal La Revue Prescribeconcluded that 68 per cent of the 3,096 new products approved inFrance between 1981 and 2004 brought nothing new to existingtreatments. A breakdown of more than 1,000 new drugs approved by the USFood and Drug Administration between 1989 and 2000 revealed thatmore than three-quarters had no therapeutic benefit over existingproducts. Pharmaceutical Industry as Investors
Advertising with Incomplete Information 2005 study of Psychobiology of the Paulista Medical Schoolof the Federal University of So Paulo Brazil Analysed 24 Brazilian advertisements for the samepsychoactive drugs as advertised in American and/or Britishpublications from the same period. Observed that Brazilian advertisements omittedinformation on usage restrictions, such as contraindications,adverse reactions, interactions, warnings and precautions,and that such information was present in American andBritish advertisements. How They Do It? --- Drug Promotion is the Key
Increasing the perceived frequency and/orseverity of the indications. 2.Widening the indications to include more people. 3.Increasing the perceived likelihood andmagnitude of benefits. 4.Decreasing the perceived likelihood andmagnitude of harms. 5.Increasing the use of the drug for longerdurations. Pharmaceutical Gifts in Pakistan
Low cost: pens/pads/diaries/calendars. Medium cost: stethoscope/books/briefcases. High cost: air conditioners/laptops/desktop computers/club membership. The latest practice is: For writing 200 prescriptionsof the companys high priced drug, a doctor isrewarded with the down payment on a brand newcar. What about in Indonesia?? Doctors Biased Behavior
Evidence shows that biased doctors are more likely to: Prescribe a drug if they had recently attended a sponsored eventby the manufacturer. Prescribe a drug that is not clinically indicated. Have a drug placed on a hospital formulary. *Governments Key Recommendations:
Implement, improve and monitor legislation in line withthe WHO Resolution on the Rational Use of Medicines andthe WHO Ethical Criteria for Medicinal Drug Promotion. Support the provision of independent information ondrugs for consumers and health professionals. Implement and enforce a ban on gifts to doctors. Enforce strict sanctions that will deter poor corporatepractice in drug promotion. Take measures to improve the transparency of drugcompanies marketing activities and seriously address theconflict of interest encountered in drug companiesfunding of medical education. **Key Recommendations at the Company Level:
1. Stop the practice of gifts to doctors 2. Implement rigorous policies on vetting of drug promotion materials and adherence to existing codes of conduct 3. Provide transparent and verifiable information on the precise nature of relationships and associated funding for all stakeholder groups, including health professionals, pharmacists, students, journalists, clinical research organizations and patient groups. **Industry-Wide Level:
1. Ensure codes of conduct on drug promotion extend to interactions with health professionals AND consumers. 2. Invest in innovative partnerships with government and civil society organizations so that corporate funding of disease awareness campaigns, and CME may be channeled via blind trusts in line with specific health priorities of consumers at a community or national level. Bibliography Drugs, Doctors and Dinners: How drug companies influence health inthe developing world Managed Care and the Morality of the Marketplace(NEJM, 333:50-52, 7/6, 1995) How to maintain the humanitarian aspects of health care?
Professionalism and ethics are the key to maintain humanitarian aspects of healthcare How to Execute Ethical Principles in an Organization?
Organizational Goals Approach The Stakeholder Analysis Approach Ethical Justifiable Decision Organizational Goals Approach
Institutional mission statements are commonly expressed thedevelopment and implementation of organizational goals An ethical analysis of organization behavior can be conceived as ameans of ensuring that an appropriate mission statement is adopted,kept up date, and put into effect The J&J case (1982) a 350 words credo First, responsibility of the company is to healthcare professionals andcustomers who use its products Useless mission statement:
To improve the total health of our communities, working inpartnership with the people we serve A hospital has ethical responsibilities deriving from its organizationalroles as employer and business entity Institution Its physician Other care givers Employers Individual patients and families Community as a whole The Woodstock Ethical Framework
Compassion and respect for human dignity Commitment to professional competence Commitment to a spirit of service Honesty Confidentiality Good stewardship and careful administration Model Hospital Mission Statement (1)
It is the goal and mission of general hospital to: Offer care to all without regard to race, religion,or ethnic identity and to the extent thatresources permit, irrespective of the ability to pay Offer health and wellness programs and healtheducation to the people of our service area Provide the best available medical care to ourpatients honoring their rights to determine thecourse their treatment Model Hospital Mission Statement (2)
Employ open and ethical business practices in ourdealings with patients, professional associates, alliedservice providers and business partners Provide a fulfilling place of employment to ourprofessional staff and employees including appropriatecompensation, healthful working conditions, andopportunities for education and advancement Use the resources provided by benefactors, foundations,and public entities as efficiently as possible in the pursuitof these goals Stakeholder Analysis Any group or individual who can affect or is affected by thecorporation (Evan and Freeman, 1988:100) Primary stakeholders: groups whose continued participation isnecessary to the survival of the organization (e.g. shareholders,employees, customers, suppliers, creditors, and governments) Secondary stakeholders: groups whose participation is not essentialto the organization, although they are affected by organizationalactivities (e.g. media, community, and other business) Remember the Formula Organizational Goals Approach
The Stakeholder Analysis Approach Ethical Justifiable Decision Thank You for your kind attention