What is the role of law in society?
- regulate behaviors ex.) safety = wearing seat belts
- collective idea of safety for everyone ex.) quarantine
- routine is important
Law
is composed of rules of conduct established by people to maintain peace and productivity in society and prescribed or recognized by a supreme authority
- what must be done
- avoiding chaos and organizing society with laws
~order
~peace
~productivity
~cust
What role does/should government have in healthcare?
FQHC
hope well - won't turn away low income people
What is the role of ethics in our society?
law, we have an authority
Ethics
is a system of beliefs and behaviors that people value and use to control their conduct
- what should be done
- the study of moral life
Ethics in Healthcare
- bioethics
- professional standards
- business/organizational ethics
- ethics in research
- ethics recommendations
History in Health Administration
1976 Quinlan Case (New Jersey)
- firt legal case to adopt the idea of a healthcare facility should establish an ethics committee
ex.) removing treatment for ventilators or life support because doctors could be sued or charged with murder - hospital goes to court to get an order so ever
1986 American Hospital Association Handbook for Hospital Ethics Committees
3 primary functions:
- educating medical staff, hospital staff, and patients
- developing policies
- consulting and reviewing cases
Common Issues Addressed in Healthcare
- advance directives (do not resuscitate) ~ make your wishes known, legal document about health
- do not resuscitate processes
- patient refusal of services
- withholding life sustaining treatment ~ futile care
- medical futility ~ treatment beyond benefi
What is the relationship between morals and ethics?
are they the same?
- both relate to "right" and "wrong" conduct however; ethics are provided by an external source; are you on board or not?
*refer to chart on slack
morals come from family, religion, culture, & environment
What is the relationship between law and ethics?
Law - system of rules by which international relationships, nations, and populations are governed
Ethics - principles and values used by an individual or group to govern his or her actions/decisions
Law:
- consistent, universal, well published, accepted,
Complexity of Healthcare Regulation
Gross Domestic Product --> 17% --> projected to be 20% in healthcare
opposing interests (both historical and current)
- stakeholders: government = payer, providers, insurance companies, patients, hospitals/organizations
- complex web of oversight
- concer
Complexity of Healthcare
Medical school - received accreditation by private body
Pass national exam - administrated by private body
Obtain licence - from state medical board
Complete residency - funded and governed by federal government (Medicare)
Achieve certification - from pri
How do we reform healthcare?
- change the laws that regulate the system
- reforms aim to address: cost, access, quality = priorities of U.S. healthcare
- we talk a lot about healthcare when we should be talking about health insurance
- having health insurance doesn't mean you have ac
A Right to Healthcare?
it's circumstantial:
everyone = EMTALA
- statutory right to be seen and have condition stabilized
Insured
- contractual right to covered benefits
M.D./Patient Relationship
- contractual right to treatment without abandonment
U.S. Government
- certain popu
The Judicial Branch
Common Law - body of legal principles and precedents that were established by courts
The Legislative Branch
writes the laws
The Executive Branch
Rulemaking - the procedure by which administrative agencies propose and adopt regulation to implement a statue enacted by the legislator
Separation of Power
The division of authority:
- Legislative, executive, and judicial branches of government, at both the federal and state levels
Federalism
the relationship between federal and state governments
- the powers of each level of government are subject to constitutional principles
Sources of Law
- Constitution (Supreme/Above all else)
- Statues (don't steal, drive MPH)
- Administrative Law (rule making)
- Judicial Decisions
Criminal Law
penalties for wrongs against society as a whole, even if the wrong harms an individual member of that society
Civil Law
legal rules to cover private rights and obligations of specific parties as in contracts, torts, and some violations of statues
Contract
a voluntary agreement between two or more parties that meets the requirements for a binding and legally enforceable obligation
State Courts
- trial courts
- intermediate courts of appeal
- supreme court
Federal Courts
- U.S. district court
- U.S. courts of appeal
- U.S. supreme court
U.S. Medicine 19th Century
19th century: comfort, compassion, and concern
- anesthesia
- Florence Nightingale
- Germ Theory
- antiseptic surgery
U.S. Medicine Early 1900s
early 1900s: The Medical Profession and The Hospital
- Almshouses to hospitals
- Flexner Report (1910)
- professional organizations and standards bodies
U.S. Medicine 1920s
1920s: The Birth of Health Policy and Politics
the role of government:
- 1934 Social Security
- rise of employer health insurance
- 1946 Hill-Burton Act - government grants/loans to build hospitals
- 1965 Lyndon B. Johnson and The Great Society: Medicare
U.S. Medicine Current Landscape
Health Reform:
- Patient's Bill of Rights
- Individual Mandate
- Insurance industry regulation
- Prevention and wellness
- Expansion of public programs such as Medicaid and CHIP
St. Thomas Aquinas
1225-1274
- gift to think of the potential to choose good over evil
- free will
Immanual Kant
1724-1804
- duty-based ethics
- we have obligations as a society
- everything in society has relative value
- based on action, not intent or feelings
John Stuart Mill
1806-1873
- good produces utility (benefit) and/or avoids harm
- utilitarianism
- what avoids the most harm?
John Rawls
1921-2002
- social contracts
- we have the duty to uphold basic human rights of all society
- veil of ignorance
Ethical Decision Making
How do you make an ethical decision?
According to whom?
Based on what?
Three Levels of Healthcare Ethics
- acting ethically as individuals
- creating ethical healthcare system
- making government and society it represents become more ethical in the ways it treats members of society
Healthcare is seeking:
- firm foundations
- reasonable principles
- helpful guidelines to assist in making ethical decisions
Principles in Healthcare Ethics:
- respect for autonomy
~ self direction
- nonmaleficence
~ do no harm
- beneficence
~ to do good
- justice
~ equality, you get what you deserve
Rules in Healthcare Ethics:
- veracity
~ truth-telling
- confidentiality/privacy
- fidelity
~best interest of the patient
Ideals in Healthcare Ethics:
- forgiveness
- generosity
- compassion
- kindness
- with concern for dignity
Shared Values
accepted ethical principles of what constitutes compassion, fairness, and justice for all members of society
A Process
- could the result involve actual or potential burden/harm to individuals or the healthcare system?
- could the result violate what society generally considers ethical behavior or what the law defines as lawful?
There is a recognized model to ethical decision making:
1. recognize the issue
2. gather relevant facts
3. put all decision making models on the table
4. evaluate why the different models are valid
5. apply the appropriate models
6. make decisions based on models
7. monitor results of those decisions
8. repeat
Social Media Model
- a decision is ethical if it withstands public scrutiny
- The Smell Test
1. define what the reaction would be based on popular opinion
2. use information to make ethical decision
3. monitor results
strengths: focuses on public, emotive based
weaknesses:
The Utility Model
- a decision is ethical when it maximizes good and or minimizes harm to the greatest number
- outcome focused
- utilitarianism - the ends justify the means
- John Stewart Mill
~ the right course of action is the one that produces the greatest benefit
- du
The Rights Model
- a decision is ethical if it respects and guarantees the human rights of the person affected
- does not apply to every scenario
- the rule of law and principles of ethics about what is owed to people based on certain principles that are accepted by socie
Rights
claimed entitlements arising from the nature of humanity and freely granted by law without the obligation to do anything
Privilege
restricted right or benefit
Moral Rights
universal rights that apply to everyone in similar situations
- not easily subject to change
Legal Rights
human constructs created by society enforced by government and subject to change
Vulnerable Populations
is a social group that experiences health disparities as a lack of access to healthcare and therefore face increased exposure to health risks
The Exceptions Model
a decision can be considered ethical when a benefit given to one person can become a normative standard of conduct toward all persons
The Choices Model
- requires that persons make their own free and independent choices
Negative Moral Rights - permit inaction; one may refrain from acting or others may refrain from acting
Positive Moral Rights - require action; one must act or others must act
Justice
equals should be treated equally and like things treated alike
Distributive Justice
the extent to which society's institutions ensure that benefits and burdens are distributed among society's members in ways that are fair and just
Market Justice
individual resources determine distribution
Social Justice
distribution should be based on need not resources
Compensatory Justice
the extent to which people are fairly compensated for their injuries by those who have injured them
Traditional perspective of the patient:
- dominated by physicians
- compliance
The ethics of paternalism:
- moral duty to do no harm (nonmaleficence)
- moral obligation to use their knowledge (beneficence)
The Sick Role
- benefits
~ exempt from normal roles
~ not responsible for condition
- responsibilities
~ must get well
~ must seek competent help
The shift from paternalism:
- patient centered care
- how? why?
- contributing factors: insurance coverage and increased technology
The Patient Culture Evolution
- patient subcultures
~ patient-partner
~ compliant patient
~ non-compliant patient
The Patient Bill of Rights
The Consumer Bill of Rights and Responsibilities
- adopted by the U.S. Advisory Commission on Consumer Protection and Quality in the Health Care Industry 1998
3 Major Goals:
1.) help patients feel more confident in the U.S. healthcare system
a.) assures a
Major Provisions
*choice of providers and plans
- right to choose healthcare providers
*access to emergency services
- you have the right to be screened and stabilized using emergency services
*taking part in treatment decisions
- the right to know your treatment options
The New Patient's Bill of Rights
- Part of the ACA is a new patients bill of right
- consumer protection to which patients are entitled
- young adults under 26 can stay on parent's health insurance policy or be added to it
- bans preexisting condition exclusions: Job Lock = scared to get
Right to Emergency Care (pt.1)
- a moral right
Human Solidarity - the recognition that human interests and responsibilities are mutually shared
- a legal right
1986 Emergency Medical Treatment and Active Labor Act (EMTALA)
Right to Emergency Care (pt.2)
The ACA has attempted to correct some of these practices:
- insurers can no longer charge higher cost-sharing for emergency care obtained out of network
- insurers must reimburse out-of-network providers for emergency care
- insurers cannot deny payment f
Safety Net Hospitals
deleivers a significant level of uncompensated care to the uninsured and patients with government insurance
Critical Access Hospitals (CAHs)
designation given to certain rural hospitals by CMS (only 25 beds and open 24/7)
- often these are the only access point to emergency/trauma care
Right to Receive Care
The U.S. government has no constitutional obligation
- legal principles and precedents established by courts and policy give Americans the right to emergency care but not to financial coverage of care
- could collect, charity, uncompensated, or cost shift
EMTALA
EMTALA the anti-dumping law
- enacted by Congress in 1986 as part of Consolidation Omnibus Budget Reconciliation Act (COBRA)
- Hospitals cannot transfer uninsured or Medicaid patients to public hospitals without providing a medical screening examination t
Medical Screenings
*must provide appropriate medical screening
*1989 amendment
- screening cannot be delayed to inquire about method of payment or insurance status
Transfer-Antidumping
transfer must:
- be requested by patient or physician
- benefits must outweigh risks
- must have agreement from accepting facility
Consent
the freedom to think and act without being constrained (approval/permission)
Informed Consent
the patient understands the procedure/treatment to be given and gives explicit permission for its implementation
What does informed mean?
Requirements:
- competence
- voluntariness
- disclosure and authorization
Competence
the ability of a person to understand the procedure or treatment
Voluntariness
the state in which the patient is not forced into making a decision
Disclosure and Authorization
the patient or his or her designee gives permission for a procedure or treatment
Precondition: Competence
- requires that a person is capable or has ability to make decisions
- complex
- generally adults assumed to be competent and children assumed not to be
Precondition: Voluntary
- a right to consent without penalty
- a right to refuse treatment
Precondition: Authorization and Disclosure
- both a legal and ethical consideration
- Reasonable Person Standard - the level of information that a patient must have to be considered able to make the decision
Reasonable Understanding
- diagnosis
- proposed treatment
- risks and benefits of treatment
- alternative treatments and their risks and benefits
- prognosis with and without treatment
- probable course of recovery
- consequences of not consenting
What can threaten the ability to disclose/receive consent?
- literacy
- comprehension
- access to information
- language or culture barriers/differences
The legal aspects of informed consent:
- 1914 started having discussion about consent ***know this date
The Patient Self-Determination Act of 1990 (PSDA)
requires all facilities receiving Medicare/Medicaid:
- advise patient of right to make decision
- explain advance directive policies
- educate staff on these topics
Advance Directives
consent when you can't
- putting your preferences in writing
- do not resuscitate (DNR)
- Living Will - spell out what types of medical treatment a person wants at the end of life if she's unable to speak for herself
- Health Care Power of Attorney - appo
Ohio Advance Directive
State of Ohio Health Care Power of Attorney
- authority of agent to consent to administration of pain relieving drugs or treatments and procedures
- make decisions regard life-sustaining treatment
- withdraw or refuse treatment
- request, review, and rece
Whose responsibility should it be to protect patient privacy?
- physician (patients must provide correct info)
- employer
- receptionist
- patient's themselves
Privacy
an agent's control over access to himself or herself
Ethical Principles and Privacy
- personal autonomy (the ability to make personal decisions)
- individuality
- respect
- dignity and worth as human beings
Privacy and the Law
- privacy received little attention in law or legal theory until the late 19th century
- 1965 Supreme Court discuss privacy right in case concerning family-planning
The Government's Role in Protecting Privacy
Privacy is largely governed by State laws
- great variation between states
- federal regulations do not preempt more protective state laws
The Privacy Act of 1974
Federal Law
- regulates the collection, maintenance, use, and dissemination of personal information by federal executive branch agencies
- enacted to safeguard individual privacy from the misuse of federal records
- not healthcare specific
The Health Insurance Portability and Accountability Act of 1996 (HIPAA)
- Federal law enacted by Congress and signed by President Clinton in 1996
- The most significant federal involvement in patient privacy
- aim focused on transmission of electronic health information improving as a way to improve efficiency within healthca
Who is responsible for privacy?
Covered Entities:
health plans, healthcare clearinghouses, and healthcare providers that transmit information by electronic means
Health Information
any information, whether oral or recorded in any form or medium that
Protected Health Information (PHI)
any health-related information that identifies or can be used to identify the individual to whom it pertains
- names
- small geographic areas
- birthdates
- phone
- social security
- photo/images